An Outline Of Psychiatry For Students And Practioners

AN OUTLINE OF PSYCHIATRY

FOR STUDENTS AND PRACTITIONERS

BV

THE LATE

FRANK FISH, M.B., M.R.C.P., M.R.C.P.E., D.P.M.

Preftsior o/ f^thialry, cf Lhtrpool

WITH A FOREWORD BY

G. M. CARSTATRS. M.D., F.R.C.P.E., D.P.M.

Proftu^r of Ptytholi^tol Mtdictn*

Unttfraty cf K<ltn^tgk

JECONO eortiON

BRISTOL: JOHN "WRIGHT & SONS LTD.
1968

© JOHN WRIGHT & SONS LTD.. 1568

Dittrtbatioii by Sole Agentt;

United Stetlei oj Ameneat The WWiami & Wilkins Company, Baltimore
Canada: The Maemtlan Company of Canada Ltd., Toronto

FinteJitiaa, 1064
SftoftJ * 4 itaon, t^8

SBN 72]t 0222 0

IN CHUT nUTAIM BT JOHN WUCKT AKD (ON3 LlO .
T tKt nWEBMOCe rBBS, BROTOL. B54 JM)

PRINTED

PREFACE TO THE SECOND EDITION

Professor Fish was always extremely self-critical and this trait is
reflected in the second edition of this book, for he strove in the last
months of his life to bring greater clarity and consistency to certain
parts of the text.

The general style and orientation remain unchanged. The sections
which dealt ^vith neuroses and psychopathic personalities have been
completely rewritten and are now more consistent with the systematic
teaching of Kurt Schneider and Leonhard. Abnormal personalities,
which include psychopathic (antisocial) personalities, receive separate
treatment and the whole conc^t of the abnormal personality is thus
high-lighted as a quantitative deviation from the norm. Similarly,
psychogenic reactions and developments in the Jasperian sense are now
discussed in a separate chapter. Professor Fish hoped by making these
changes to clarify the position of those non-psychotic conditions which
are not the result of a morbid pathological process.

Other chapters have been enlarged, particularly the one devoted to
psychosomatic disorders.

The psychiatric organic states have been classified difl'erently in the
hope of avoiding some of the pitfalls which are met when the terms
‘ ,, ‘ »ihas3itft’ asjil ‘ cbsavic’ ase. Th.\x baa,

extensively retmtten and an explanatory diagram has been added.

Lastly, it may be said that any book which involves psychopharma-
cology is out of date by the time it appears in print, so that since the
first edition appeared in print a host of new drugs have become avail-
able. The more important of these receive consideration, necessitating
some expansion of the chapter dealing with treatment.

PREFACE TO THE FIRST EDITION

This book is the result of ten years’ experience in the teaching of
psychiatry to undergraduate and postgraduate students. Every effort
has been made to describe signs and symptoms carefully and to separate
fact from theory. No attempt has been made to deal with child
psychiatry or mental defidency, because neither of these subjects can
be adequately presented in a short chapter of a general psychiatric
textbook. I hope that tlus book will provide the undergraduate and
the general practitioner with the fundamentals of psj’chiatry and that
it will give the postgraduate a framework around which he can organize
his knowledge.

PREFACE

The general orientation of thfa boot is beat des«ibed as *neo-
Mej'erian'. In other tvorda, 1 belietre that in any given case all the
factors which may postibly be relevant should be considered and the
appropriate measures, based on empirical knowledge, psychoanalytic
theory, sociology, or common sense, should be applied.

The responsibility for the views expressed in this book ts, of course,
entirely mine, but I would like to take thb opportunity of expressing
my grateful thanks to my former teachers, especially to Sir Aubrey
L^is, D. L. Davies, and Robert Orton. However, perhaps this book
owes most to my Chief and friend Alexander Kennedy, whose untimely
death three years ago was a great loss to British psychiatry. Although
our ideas about p 3 }*chiatry often diverged, he always encouraged me to
express my own point of view and never attempted to impose his views
on me. I hope that this book will encourage the development of
psychiatric education in Britain — a cause to which Alexander Kennedy
devoted his life.

F. J. F.

Department oj Ptyeholagteal Medicine,

Univertity of ^tnburgh.

January, 1964

ACKNOWLEDGEMENTS

Thanks are due to the following: Cassell tc Co. Ltd., for per-
mission to quote from Emotion and Personality, by M. B. Arnold;
the Editor of the British Journal of Psychiatry, for permission to quote
from an article by J. Inglis (1959). J. ment. Sd., 105, 440; The
IVIlliams & IVilkins Company, Baltimore, for permission to quote
from The Measurement of Intelligence, by D. Wcchsler; Professor
G. M. Carstaiis, for permission to print the case-taking scheme used
in the Department of Psychological Medicine, University of Edinburgh;
Professor Karl Leonhard and \'EB Verlag Volk und Gesundheit for
permission to use material from Dijffrrenxierte Diagnostik der endogenen
Psychosen, abnormen PersbnliehkeilsstTukturen und neurotisehen Ent-
xcieklungen’, and Wiliam Heinemann Medical Books Ltd., for
permission to quote from Heredity and Environment in the Functional
Psychoses, by E. Kringlen,

CONTENTS

CHAPTER PACE

Foreword - -.-.---vii

I. — Aetiology and General Principles - - . - i

11 . — The History op Psychiatry and the Development

OF Modern Clinical Psychiatry - - - - io

in. — ^The Schools op Psychiatry ----- 24

IV. — General Symptoiutolocy 35

V. — ^Abnormal Personalities ------ 63

VI. — Psychogenic Reactions, Personality Developments,

AND Neuroses - - 874

VII.— Psychosomatic Disorders 88

Vin.— Drug Dependence - 100

IX.— ArFEcm'E PsTaiosES and Manic-depressive Illness 113

X.—ScHuopHREmA AND Paranoid Stato - - - 126

XI.— Psychiatric Organic States: General Principles - 139

XII- — Psychiatric Organic States: Specific Illnesses - 148

XIII. — Sexual Disorders ------- 167

XIV. — ^The Treatment and Management op Psychiatric

Disorders - .- .- -- .183

XV. — Psychiatry and the Law . . - _ . 224

XVI. — The Electro-encephalograph in Psychiatry - - 238

XVII. — ^Metood in Psychiatric Case-takino - - - 241

Further Reading List ------ 24S

Gloss.\ry - -- -- -- - 254

Index - 277

FOREWORD

G. M. CARSTAIRS

Pn/utorof Fsythelotiul itedume, Umvertity of Edinburgh

It is only too well knoAvn that a majority of medical students, and
doctors, find psychological medicine a ‘difficult’ subject.

A patient’s temperature and blood chemistry, or his response to
anticoagulant therapy, can be observed trith precision, but his emotional
state can be assessed only subjectively, that is, by resort to a type of
observation which scientists have been taught to distrust, ^\^lat is more,
psychiatric teachers have to admit that sound aetiological understanding
has been reached in respect of only a fe\v of the disorders which they
treat; the rest are hedged about vtith surmise and the weighing of
alternatives.

Until basic knowledge in our spedalty adv'ances, psjxhiatrists will
have to tolerate this uncertainty; but they are not obliged to dwell upon
it in their teaching. On the contrary, it is possible to show that many
of the clinical phenomena of psychiatric illness can be observed
systematically and can be descril^d in dear-cut terms; tbb has been
Dr. Fish’s principal aim in preparing his Outline of Psychiatry.

This book is firmly based on ten years’ experience of teaching
psychiatry to undergraduates, to general physicians, and to psychiatrists
in training. Dr. Fish does not hesitate to be dogmatic in the cause of
greater clarity. He does so deliberately in the knowledge that a firm
statement of opinion is more likely to stimulate thought (and even
constructive disagreement) than one which is hedged about with
cautious qualifications. His own allegiances are not concealed; for
Dr. Fish, Emil Kraepelin is ‘ probably the most outstanding psychiatrist
who ever lived ’, and his example as a clinical obsenxr and systematizer
has certainly inspired the preparation of this book. Dr. Fish has
carried the same principles of clear-cut description of clinical phenomena
and terse exposition of theoretical interpretations into his account of
recent developments in psychiatric thinking and of new forms of
treatment, whether in hospital, in the clinic, or in the communlt)’.

In putting forward this deariy stated, personal, and at times provoca-
tive outline of psychiatric knowledge as it stands today. Dr. Fish has
demonstrated to a wider audience the gifts of exposition which have
been appreciated by succesrive groups of his undergraduate and
postgraduate students. The prospectiTC reader can be confident that,
when he has finished tWs bmk, he will have a clearer idea of what
p*sychiatry is all about.

*11 faut aimer les a1i6i& pour £tre digne et
capable dc Jcs acn-ir.’ — EsqtriROL.

AN OUTLINE OF PSYCHIATM

CHAPTER /

AETIOLOGY AND GENERAL PRINCIPLES

THE NATURE OF PSYCHOLOGICAL THEORIES

Explanatory Psychology. — In natural science an attempt is made
to establish causal connexions. By means of observations and experi-
ments rules arc discovered and with further in\estig3tions laws
are established which, in the end, can be expressed in the form of a
mathematical equation.

In morbid and normal psychology the same sort of investigations
ate carried out, for example, we know Aat stimulation of the brain can
cause halludnations or forced movements. This type of psychology
can be called ‘explanatory psychology’.

Empathic or Understanding Psychology. — We are all able to
empathize with our fellows to some degree. When we do this we feel
our way into the situation of the individual and understand his
behaviour. In this way we esublish an understandable connexion
beuveen psycholopcal events. Thus we understand that the man who
is attacked phjalcally or verbally will become angry and defend himself
in some way.

Interpretative Psychology. — Simple understanding of our fellows
soon develops into interpretations of their behaviour in terms of some
ideas borrowed from folk-lore, science, or philosophy. The psycho-
therapist is forced to organize his experiences of the behaviour of
patients in some tvay. Thus, different varieties of interpretative
psychology have arisen which are dependent on the background and
personality of the originator.

The Nature of Psychological Explanations. — In any discussion
of psychopathological phenomena one must be sure of the type of
psychology which is being used and not confuse ideas taken
from explanatory psychology with those from understanding and
interpretative psycholog)’.

2 AN OUTLINE OF PSTCIIIATRT

THE CAUSATION OF PHYSICAL DISEASE

Often false concepts of the causation of physical disease are carried
over into psychological medidne. Thus an infectious disease such as
pulmonary tuberculosis is regarded as being caused by the tubercle
bacillus, but if this were so, then all of us who have been exposed to
infection would develop pulmonary tuberculosis. This would also
not explain the increased inddence of the disease in certain age-groups
and races. So that, while the tuberde badllus is the essential cause of
the illness, a large number of other factors, such as the inherited
constitution, the endocrine balance, the diet, overcrowding, and so on,
may determine the onset of the illness.

THE CAUSATION OF MENTAL ILLNESS

There is no reason to suppose that the causation of mental illness is
different from that of physical illness. As wc are uncertain of the
essential cause of many nervous illnesses, it is necessary for the
psychiatrist to take into account all factors which could possibly have
played a pan in the production of the illness under consideration.

< Mental illness should be regarded as the response of the individual to his
jlife situation. When we see a mentally sick person w'e must ask the
^threefold question: ‘Uliy did this person break down, in this way, at
.this time The answer is to be found in:—

X< The Immediate Situational Stress,—

a. Living conditions.

b. Family relationships.

e. Interpersonal relationsbips outside the home.

d. Occupational adjustment.

e. General sodal conditions such as economic crises, war, etc.

/. Physical illness.

2. The Constitution. — ^This is the sum total of all the phj’sical and
psychological predispositions of the indindual and is detennlned by: —

a. Genetic factors. Sometimes this aspect of the constitution Is
meant when the word is used. In this case the term ‘genetic
constitution’ should be used.

b. Physical damage to the nen'ous system caused by intra-uterine
and postnatal disease and trauma.

e. Psychological influences during development.

GENETICS OF MENTAL DISORDER

Methods of Study. —

I. Family Histories of Mental Disorder, — In mental disorders in which
psychological factors may play a part, the increased incidence In the

cluldien of patients may be due to the psychological effect of parent on
child, thus giving a false idea of the genetic basis of the illness.

2. Incidence of Cousin Marriages in a Given Illness. — If the condition
is inherited as a Mendelian recesave, then there will be an excess of
cousin marriages among patients with the illness.

3. Uniovular Tscin Studies. — ^noe both utuovular twins have the
same genetic inheritance, they should both suffer from an inherited
disease if one of them develops it.

Inheritance of Sperifie Mental Illnesses. —

1. Huntington's Chorea (seep. 156). — ^Thisis inherited as a Mendelian
dominant so that 50 per cent of the offspring of a patient will develop
the illness, which is a progressive dementia usually beginning over the
age of 35 years. If the illness tends to appear late in life, then predisposed
persons may die before the illness manifests itself and it may appear to
miss a generation.

2. Schizophrenia (see p. 126). — The expectation of the illness in
different groups is: The general popubtion, o-8 per cent; siblings of a
patient, 7'0 per cent; children of a patient (simple or hebephrenic),
10 per cent*, children of a patient (paranoid or catatonic), 22 per cent;
grandchildren of a patient, 3 per cent; nephews and nieces of a
patient, 2 per cent; hrst cousins of a patient, 2 per cent

In Sbteris series of 41 uniovular twins, in which at least one member
was schizophrenic, the other twin also suffered from the illness in
76 pec cent of cases. However, a few twins of schizophrenics we*re
perfectly normal psychiatricaliy. This contradicts Kallman’s claim that
the heterozygote is a schizoid personality and the homozygote is a
schizophrenic. Recently, Book has suggested that the mode of
inheritance is recessive with manifestation in one-fifth of heterozygotes.
Many psychiatrists believe that schizophrenia is genetically determined,
but other genes and psychological and physical factors probably help to
determine the onset of the disease. However, Jackson has pointed out
that there arc many weaknesses in the genetic investigations of
schizophreiua. It is also possible that schizophrenia and manic-
depressive insanity are not as sharply separated as is often believed.
Kringlen has summed up the result of tvrin investigations as follows.
In the main, the concordance figures for schizophrenia are found to be
25-38 per cent in monozj'gotic twins and 4-X0 (iz) per cent in dizygotic
twins, according to whether the concordance rates are based on
registered hospitalized cases or personal investigations, and whether a
xvide or strict concept of schizophrenia is employed. The difference
in concordance rates for monozygotic and dizj’gotic twins with respect
to schizophrenia is statistically significant, thus supporting a genetic
factor in the aetiology of schizophrenia, but the genetic factor seems to
be weaker than it is usually conridered to be.

4

AN OUTLINE OP PSYCHIATRY

3. Manic-depressive Insanily {see p, 113), — ^The general ^ew is that a
tendenty to marked mood variation is inherited, rather than the actual
illness, as a simple autosomal dominant The expectation of the illness
is:Parentsofapatient, 10-2 per cent; cluldrenofapatient, I2*8 percent;
general population, 0*4 per cent.

y/ The Importance of Genetics in Mental Disorders. — There is
no doubt that in some psychiatric illnesses inheritance plays an
important part in causation, but often it is not the only factor. Physical
and psychological factors may determine the exact point of onset of the
disease. The sharp contrast between environment and heredity is false.
Some psychiatrists neglect the genetic aspects of their work because
they feel that, if the illness is inherited, treatment is useless. This is not
so, since inhented biochemical defects can be treated.

It is equally one-sided to deny the importance of psychological factors
in the causation of mental illness, since neglect of such factors may lead
to inadequate psychotherapy or even to a recurrence of the illness.

Chromosome Abnormalities. — Recently it has been found that
some patients have too many or too few chromosomes. One extra
chromosome is known as trisomy. Trisomy of the twenty-first
chromosome occurs in most cases of mongolism. The Klinefelter
syndrome, in which the male individual has an extra X chromosome
and is XXY instead of the usual XY, does occur in mental defectives and
schizophrenics, but there is as yet no evidence that it causes schtzo*
r^^enia, although it might be a contributory factor in predisposed
■‘‘‘persons.

J COARSE DRAIN DISEASE AND MENTAL ILLNESS
{See also Chapter XI)

The genetically determined brain diseases have already been dealt
with. Apart from these, mental illness can be caused by damage to the
brain due to inflammations, anoxia, wounds, ischaemia, and so on.
These u^ally produce non-spcdfic syndromes, but schizophrenic or
manic-depressive clinical pictures can occur {see p. 144).

Mild brain damage occurring before birth or in early childhood may
not produce mental deflciency as severe damage does, but may make
the child more liable to childhood behaviour disorders or childhood
schizophrenia. The disturbance of normal psj’chological de%'elopment
produced by such mild brrin damage may produce a grossly abnormal
personality.

There may bea complicated interplay between the direct psychological ^
effects of brain damage and the psychological difficulties due to the I
disturbance of the environment by the sj-mptoms produced by the J
coarse brain disease. Thus, in epflep^, the fits may make it difficult to

AETIOLOGY AND GENERAL PRINCIPLES 5

find work and may cause a revulsion on the part of fellow employees,
while the epileptic personality change leads the epileptic to antagonize
his fellows. It may be diffictdl to attribute the degree of the responsi-
bility of the different factors in the epileptic’s maladjustment.

PSYCHOLOGICAL INFLUENCES DURING DEVELOPMENT

Parental Attitudes. — The .child’s fir st en vironment is its«mother.
LaterAfather andlsiblings may influence the child, and still later the
Mschool and thefiieighbourhood. The inSuence of the mother on the
child is determined by the mother’s attitude and the child’s constitution.
For example, a donunant, over-possessive mother may produce
different disorders in different children. There are the following
possibilities: —

1. A passive child who cannot protest. Such a child may develop into
a model child and later into an inadequate personality or even a
homosexual.

2. An active child who tolerates frustration to some degree may
develop tics which are a partial protest.

3. An overactive child with a low tolerance to frustration may show
grossly disturbed behaviour and be beyond parental control.

y Maternal Deprivation.—

Facts.— Thrte different experiences seem to be prone to produce an
affectionless psychopathic character: —

1. Lack of any opportunity for forming an attachment to a mother
figure during the firat three years of life.

2. Maternal deprivation for a liimted period of at least three months
during the first three or four years of life.

3. Frequent changes of mother figure during these early years.

Theories and Clinical Findings . — Maternal deprivation could possibly

be a contributory factor in the causation of the major functional
psychoses. Affectionless psychopaths who have ne^’er suffered from
maternal deprivation can be found.

Evidence from Ethology. — ^Many animals have complicated
patterns of behaviour which arc released by relatively simple combina-
tions of stimuli. If at the time of the first emergence of su^ a pattern
the developing jtiung animal is exposed to an artificial set of stimuli
which conform to the general cotiiSguration necessary to release the
behaviour pattern, then the animal may learn to release the pattern of
behaviour when presented with the artificial stimuli, but not when
presented with the natural ones. Harlow has shown that baby monkeys
reared away from their mothers on arrificial mothers which have
accessible supplies of milk, may show antisocial, behaviour if the model

6 AN OUTtlNB OF PSYCHIATRY

mother is made of wire and ‘her* body has not tlic normal texture of
monkey fur.

SOCIAL ENVmONMENT

Distribution of Schizophrenia and Other Psychoses in Urban
Areas. — Paris and Dunham in 1939 showed that the rates for schizo-
phrenia in the central areas of Chicago were higher than in the periphery.
In the central areas the social and economic conditions were poor and
there were many more people living alone. On the periphery of the city
in the ^vealthier residential areas the schizophrenic rate %vas lowest.
Senile and arteriosclerotic dementias showed a similar but less marked
distribution. Manic-depressive insanity was more evenly distributed
with a tendency to higher rates in the better-class areas. The
conclusions were that 8oci^_jsolaiioa.causedjclu2ophrenia. These
findings have been confirmed in nine different American cities. Hare
(1956), in Bristol, found a iugh rate of schizophrenia in the central areas,
which were composed of a poor area and a middle-class area, in both of
which there was much social isolation. The rate was low in the peripheral
areas, composed mainly of working-class municipal housing estates,
where very few people were living alone. Hare concluded ^at these
findings could be explained as due to pre*psychotic drift of the pre-
disposed individuals to areas of social isolation and also to the effects of
social isolation.

Other Studies of Social Isolation. — In the United States there is
an excess of schizophrenia among immigrants. This may be due to poor
diagnosis because of langu^ difficulties and the self-selection of
abnormal personalities for immigration.

Schizophrenia rates arc ako Wghcr among Norwegian seamen than
among the general papulation. This may be due to the higher incidence
of abnormal personalities among seamen.

The objection to the possible causative role of social isolation is that
the apparent excess of schizophrenic psychoses may be an excess of
atypical psychoses which tend to occur in abnormal personalities who
are likely to drift into social isolation.

Occupation. — During World War II neuroses were found to cause
a large amount of absenteeism in one English investigation. Since a
doctor’s certificate was necessary if the worker stayed at home, and
many of the workers had been directed to work that they did not care
for, then the doctors’ certificates of ‘neurosis’ were probably more
indicative of malingering than of illness.

In another study there was no awrelatitm between ncuroas and poor
output in the factory.

(^rtain occupations are at ri^ for alcoholism, viz., those in the drink
trade.

AETIOLOGY AND GENERAL PRINCIPLES 7

War. — Mental hospital admisaons decline during major war^nd it
is claimed that ‘endogenous p^choses' do as well, so that^hese
psychoses are not truly endogenous but partly produced by stress.
This is probably fallacious, since mental hospital admissions do not
necessarily directly reflect the inddence of psychoses in wartime.

Prison. — True prison psychoses (‘stir crazy’) occur in abnormal
personalities who react badly to prison.

Schizophrenia in prison may be the clear appearance of the illness,
the prodromal symptoms of which led the person to commit a crime.

STRESS AND REACTION

Stress. — If this word is used to mean all the difficulties with which
the person is faced, then stress is not a matter of all or nothing, but of
degree. Given enough stress, anyone will break doum.

The liability to breakdown depends on the nature of the stress for the
person as well as on the intensiQr.

The significance of the stress cannot be estimated in a rational way
or in terms of the psychiatrist’s orvn attitudes, which themselves may be
irrational in a different way.

Attitudes and ambitions are often illogical, but if they are frustrated
then the subject may become profoundly disturbed. There is always
the difficulty of understanding too much and attributing causal
significance to events which have been produced by the abnormal
behaviour which is an essential part of the disease.

Reaction.— This word has five different meanings in psychiatry; —

1. Anactive,butmildmentalillness may be made worse by some event.

2. An individual with a defective personality caused by mental illness
may respond to his environment in an unusual way.

3. A mental illness may be provoked by severe environmental stress.

4. A mental illness may be regarded as an organic reaction, viz., a
response of the brain to a physical insult.

5. A mental disorder may be a re^:tion to the environment in the
NeuTonian mechanical sense that action and reaction are equal and
opposite.

Reactive tUnesses. — Arguments about reactive illnesses are due to
misunderstandings of the use of the word ‘reactive*.

If the word is used in the sense of para. 5 above, then the illness
conforms to Jaspers’s criteria for a reactive illness, as follows; —

a. The content of the mental symptoms has an understandable
relation with the experience which caused the illness.

}>. The illness would not have occurred wthout the experience.

c. The course of the illness is dependent on the experience. Thus if
the experience could be reversed or cancelled out, the illness would
disappear.

AN OUTLINE OF FSYCIIIATRV

If these criteria are accepted, then severe mental illnesses are rarely
reactive. The anxiety states in battle are the clearest example of this
kind of reactive illness.

However, illnesses do occur in wWch some event appears to have
played a causal role, but the subsequent course of the illness is
independent of the causal event and dependent on the individual'a
personality or his inherited predisposition to a mental illness.

Thus some typical 'endogenous* depressions appear to be touched off
by some e^^i^onmentaI upset such as losing a job, moving house, or a
bereavement, but the further coutse of the illness is autonomous
(independent of the envirorunent). These are reactions in the sense of
para. 3 above, and were called ‘provoked depressions' by Lange.

It is best not to distinguish sharply between reactive and endogenous
illnesses, but in any given case one should try to estimate the extent to
which reactive factors and constitutional predispositions play a part.

Physical Factors. — Apart from the direct damage to the brain,
there are various physical factors which may provoke or modify mental
illnesses. These are age, sex, endocrine changes (including pregnancy),
exhaustion, operations, ciimatic conditions, and seasonal variations.

X. Ag0 . — Mental illnesses appear to be commoner during puberty
and adolescence and also during the involutionary period (females,
40-55 years; males, $0^0 years). Endocrine changes are occurring at
both these times, but psychological difHcuIties are also present. Rigidi^r
increases with age, ao that the rigid person tolerates change less as he
grows older. All intellectual abilities decline with age, so that the
maiginally adjusted person may have additional diihcultiea with age.
Decline in immediate memory becomes obvious in the forties. This
may cause occupational difHcuIties.

2, Sex . — Some illnesses, such as involutional melancholia and senile
dementia, arc commoner in females, while epilepsy and sexual
disorders are more frequent in males.

3. Physiological Endocrine Changes . —

Premenstrval tension: Some Avomen become extremely tense in the
week before menstruation and may even be very depressed, with
suicidal thoughts, and may attempt suicide. Usually they improve
after the first day of menstruation. Water retention occurs during this
premenstrual phase and patients often complain of tightness of the
breasts and a bloated feeling. The tension is usually relieved by oral
progesterone compounds. Violence, unpleasant behaviour, fits in
epileptics, and poor performance in intellectual tasks are more frequent
in women just before or during mensuuation.

Pregnancy : Some chronic neurotic women say that the only time that
they feel fit and well is during pregnancy. Normally once the sickness

AETIOLOGY AMD GENERAL PRINCIPLES 9

of the first three months has clied away the second six months of
pregnancy are not stressful. On the whole, suicide and mental illnesses
are rare in pregnani^ and if they occur are more often reactions of
abnormal personaUties to an unwanted pregnancy, in particular an
illegitimate one, than major functional psychoses.

Puerperium: In the early days of the puerperium marked endocrine
readjustments are taking place and if labour has been prolonged and
much sleep lost, then a mild organic syndrome may occur with
depression, emotional lability, and anxie^. Later, worries about the
child and loss of sleep produced by feeding difficulties may produce
an anxiety state or provoke a constitutional depression. Inadequate
anankastic women, over-dependent on their mothers, may find the
challenge of motherhood too great and this may pro%’oke a depression.

Exhauition-. Physical exhaustion, particularly when associated with
lack of sleep, may produce transient confusional states in which
paranoid delusions as well as visual and auditory hallucinations may
occur.

Operations'. Psychoses foUowing operations may be produced by
exhaustion, lack of steep, biochemical disorders, infection, or combina-
tions of these factors. Sometimes the operation has been performed on
a patient who has hypochondriacal delusions due to depression; the
patient is no better despite the removal of an offending vlscus, but the
psychological basis of the illness is then obvious.

The cUtnatic conditions and seasonal variations'. Some patients seem to
be sensitive to changes in the weather. Gjesslng claimed that attacks of
periodic catatonia might be brought on by cold fronts and other weather
conditions.

The peak period for mental hospital admissions and suiddes is the
spring. A minor peak occurs in the autumn. No satisfactory reason has
been given for this.

to

CHAPTER U

THE HISTORY OF PSYCHUTRY AND THE
DEVELOPMENT OF MODERN CLINICAL PSYCHIATRY
THE VALUE OF THE HISTORY OF MEDICINE
TitE history of our subject allows us to understand the wider aspects of
psychological illnesses, to realiae the uncertainty of our present-day
concepts, and to learn from our predecessors* mistakes by realiaing that
we arc, just as they were, victims of our social and cultural heritage.
This will allow us to preserve what is best in the body of knowledge
which has been handed down to us, and to discard hampering
traditional ideas.

THE ANCIENT WORLD

Hippocrates (c. 460*355 b.c.) took a rational and empirical attitude
towards disease and claimed that epilepsy was due to natural causes and
was not ‘The Sacred Disease*. He attributed madoess to increased
humidity of the brain. He described depression, which he regarded as
due to an excess of black bile — hence the term 'melancholia*. He also
described deUrium, which he called *phrenitis’, and hysteria, which he
believed was due to the womb {hpteros) wandering about in the body.

Galen (c. a.d, 131-200) was a Greek physician practising in Rome,
who systematized previous medical knowledge. By this time most
physicians believed the theory that all diseases were due to a lack of
balance betw ecn the four humours out of which the body teas composed.
Galen claimed that depression was due to an excess of black bile, but
that if there was also an excess of yellow bile or if the excess of black
bile became overheated the melancholia might develop into mania.
This is one of the earliest suggestions that mania and depression are
connected. It should be remembered, however, that until the end of
the nineteenth century melancholia often meant any kind of insanity in
which severe mood changes occurred. Both Galen and Araeteus the
Cappadodan (c. a.O. ioo) described epileptic personality change and
dementia.

TTjc treatment of the insane varied; on the whoie t)}ey were treated
writh drugs, such as hellebore, and diversion. However, some doctors
recommended beatings, confinement in dark rooms, and general rough
handling of the patients in order to bring them to their senses.

HISTORT AND DEVELOPMENT

II

Psychotherapy. Temple Sleep. — Magical treatment \vas carried
out in the temples. The patient went to the priest with a votive offering
and slept the night in the temple. God appeared to the patient while he
was asleep and cured him.

THE EARLY CHRISTIAN WORLD AND THE DARK AGES
Possession by evil spirits as a cause of disease was a standard belief in
the Sumerian civilization (zooo B.C.). It is probable that the Jews took
over this belief from the Babylonians. By the time Christianity became
an official religion this demoniacal theory of disease %vas an essential
part of the faith. After the fall of Rome medicine in the Western world
was dominated by magical and religious beliefs.

The revival of rational and empirical medicine in the Arab world
(tenth and eleventh centuries A.D.) had little effect on psychological
medicine, because the Arabs believed In the demoniacal causation of
disease. However, Avicenna (930-1037) described the effect of emotions
on the pulse-rate.

THE MIDDLE AGES AND THE RENAISSANCE
Witchcraft.-— It U probable that witchcraft existed as a form of devil
worship and pagan practices among the European peasantry and was
the remains of pre-Christian religion. It was naturally regarded by the
Catholic Church as a heresy to be rooted out. With the Reformation
the Church became more active in its light against heresy, including
witchcraft. The Protestants based their beliefs on the Bible, so that
anyone who denied that iritdies existed was denying the Holy Writ.
Thus both Catholic and Protestant hunted for witches.

This belief in witchcraft led to the mentally ill being called witches
on account of their strange behaviour. Thus most of the cases of
iHuntington’s chorea in New England are descendants of two brothers
tt rom Bures, Suffolk, who enugrated to America in 1630 after their mother
had been burnt as a tritch. Many schizophrenics believed that they were
witches or that they were bewitched. Little was knoivn about the
causation of disease, so that death of humans and animals from natural
causes ivas often attributed to witchcraft.

In Germany, Johann Weyer (1515-88), and in Britain, Repnald Scott
(153&-99), pointed out that witches were mentally ill. However,
King James I of England firmly believed in uitches and wTote a book
in support of this belief.

In France, St. Wncent de Paul (1576-1660) claimed that many
witches were really mentally disordered and founded the mental
hospital of St. Lazare. He mote; ‘Mental disease is no different from

12 AN OUTLINE OF PSTCHIATRY

bodily disease. Christianity demands of the humane and the pmverful
to protect and of the skilful to relieve the one as well as the other.’

THE FOUNDATION OF MODERN PSYCHIATRY
Tlie humoral theory of disease ended svith the discovery that quinine
tvas a specific cure for malaria. Thomas Sydenham (1624-S9) put
forward the concept of the natural history of disease and the Idea that
diseases could be regarded as entities and not as a lack of balance of the
humours, which was specific more to the patient than the disease. In
the following years many different classifications of disease were put
fonvard. In 1761 G. B. Morgagni (1682-1771) published De ledibus et
cautis moThoTum per anatomen indagatis in which he correlated post-
mortem findings with the clinical pictures of disease. At the same time
many large new hospitals were being founded and doctors had the
opportunity of studying large numbers of patients with the same sorts
of illness.

In psychiatry, developments lagged fifty to one hundred years.
Philippe Pinel (1745-1826) in 1793 began the humane treatment of the
insane when he was appointed as Chief of the Dlcvtre, a large institution
in Paris for the custodial care of the insane. Just about the same time
William Tuke, a York merchant and a member of the Society of
Friends (Quakers), rvas horrified by the death of a Quaker Homan in
York Asylum. He persuaded the York meeting of Quakers to found a
hospital for the humane care of the insane. This hospital ^vas called
•The Retreat’ and set a standard which helped to raise the institutional
care of the insane tluoughout the world.

'The increase in the number of institutions for the care of the insane
led to the development of clinical psychiatry, while the rediscovery of
hypnotism by Franz Anton Mesmer (1734-18:5), and its more practical
use by Braid and Charcot in the nineteenth century, led to the develop-
ment of psychotherapy and psychodynaraics.

THE MENTAL HOSPITALS AND THE
‘NON-RESTRAINT’ MOVEMENT
In Britain after 1800 many private and public mental asylums iiere
built, and in England after the English Lunacy Act of 180S the local
authorities had a legal obligation for the care of the Insane. Many of
these asylums used physical restraint in the form of handcuffs, strait-
jackets, and chains. In 1835 Dr, Gardiner Hill began to remove
mechanical restraints in Lincoln A^Ium, and in 1839 Dr. John Cormolly
abolished all mechanical restraint in Hanwell Asylum, Middlesex. This
led to a decline in the use of mecbanical restraint throughout Britain,
Europe, and theU.SA. This is usually referred to as the ’non-restraint

HISTORY AND DEVELOPMENT 13

movement’. It has been alleged that to some extent physical restraint
was replaced by chemical restraint, and also that non-violent patients
suffered from the lack of restraint of the wolent ones. Thus, a mentally
ill clergyman in Hanwell Asylum wrote:

We have in this asylum, Sir, some doctors of renown,

With a plan of non-restraint which they seem to think they own ;

All well-meaning men, Sir, but troubled with the complaint,

Called the monomania of total non-restraint.

THE DEVELOPAIENT OF MODERN CLINICAL PSYCHIATRY

The Problems tobe Solved. — The nineteenth-century psychiatrists
were faced with two puzzling problems: (i) The relationship between
coarse brain disease and mental symptoms; (2) The relationship of
delusions to insanity.

1. The Relationship hettceen Coarse Brain Disease and Menial
Symptoms. — This tvas clarified by post-mortem studies, but the solution
of this problem was difficult, because most coarse bran diseases
produce non-specific clinical pictures (see pp. 16, 139) which are more
related to the extent and tempo of the disease process than to the
specific nature of the disease (see p. 139). An additional complication
was that delusions and other psychiatric symptoms occurred in
patients tvith coarse brain disease and in those whose brains were
normal at post-mortem.

2. The Relationship of Delusions to Insanity. — Some patients, such as
manics, are not deluded but are nevertheless insane, while in others
delusion is an essential feature of the madness. It was these non-deluded
patients whom Prichard (1786-1848) classified as cases of moral insanity.
The other problem was the prognostic significance of delusions. Some
patients, severe depressives in our current classification, were very
deluded but recovered, while others, whom we now call schizophrenics,
were just as deluded and never recovered.

The French School. — Since Pinel examined and made clinical
notes on the large number of patients under his care, it is natural that
the first school of clinical psychiatry was in Paris. Pinel’s most out-
standing pupil, J. E. D. Esquirol (1772-1840), was the founder of
modern psychiatry. He introduced the term ‘hallucination’ as a
perception sans objet and distinguished it from illusion. He made simple
statistical investigations of the causes of mental illness, which are to be
found in his hvo-volume book on mental disorders published in 1838.
In 1805 he pointed out that paralysis was a common complication of
insanity.

In 1822 A. L. J. Bayle presented a thesis in the University of Paris in
which he attributed the mental symptoms, delusions, intellectual

14 AN OUTLINE OV PSYCHIATRY

enfeeblement, and exaltation, to the same disease of the coverings of the
brain which produced the paraljrris. In 1824 J. B. Delaye claimed that
general paralysis was due to a disease of the white matter of the brain.
Calmeil (1798-1895), Brillarger (1809-^0), and Falret (1794-1870) all
helped to establish general paralysis of the insane (G.P.I.) as a disease
entity. Kraft-Ebing (1S40-190J) proved the syphilitic oripn cl the
disease.

This discovery of the Somatic basis of a mental illness led many
psychiatrists to expect that a physical basis would soon be found for all
psychological disorders.

The French school also laid the basis for the classification of the so-
called * functional psychoses*. J. P. Falret was Interested in suicide and
found that some depressives improved and then passed into a state of
elation, but some elated patients became depressed. He called this
closed emotional cycle la folU circulaire. Balllarger, a great neuro-
pathologist and clinical psychiatrist, studied hallucinations and
realized that sometimes they were produced psychologically. He also
described melancholic stupor, when previously all stupors were
regarded as organic. He confirmed the existence of Falret's foUe
cireulairt and called ic folie d double forme.

B. A. Morel (1809-73) was interested In the concept of degenera-
tion and considered that mental illnesses were hereditary weaknesses.
In i860 he described mental deterioration in a previously bright
boy of 14 years of age, and called this dimence pricoct (dementia
praccox).

The German SchooL — The Germans took o^^r the ideas of the
French about the middle of the nineteenth century and developed them
further. At first many of the leading figures were mental-hospital
doctors, but later the leading psychiatrists were all professors of
neurology and psychiatry in the University Nerve Clinics. From
1864 to 1889 ten ^rirs of neuropsychiatry were founded in German-
speaking universities. The first permanent chair in psychiatry in
Britain was established in Edinburgh in 1919.

The first outstanding German psychiatrist was Wilhelm Griesinger
(1817-68), who studied psychiatry for two years after qualification and
published a book on mental illness in 1845. He %vas the Professor of
Medicine in Tubingen, in Kiel, again in Tubingen, then Zurich, and
finally, in 1865, he was called to Berlin to the ne^vly founded Chair in
Neurology and Psychiatry. He was convinced that mental disorders
were disorders of the brain and helieved that all psychoses were merely
different expressions of one common disease (Einheiltpeyehose). His
successor, W'estphal, described and defined obsessions and also made
observations on homosexuality and phobias.

HISTORY AND DRYELOPMENT IS

The first step in the dassification and understanding of those varieties
of severe mental disorder not associated wth coarse brain disease ^vas
made by K. L. Kahlbaum (1828-99) lifelong friend and

colleague E. Hecker (1843-1909). Before this time several attempts
had been made to use the symptomatology, the aetiology, or the
neuropathological findings to establish a disease entity. Kahlbaum
suggested that any disease entity must conform to the following two
criteria: (i) The whole course of the illness must be taken into account;
(2) The total dinical picture must be adequately delineated.

This concept was taken up twenty years later by Kraepelin.
Kahlbaum described a severe motor disorder consisting of strange
attitudes, odd movements and postures, together with stupor and
menial deterioration, in a monograph. Catatonia or Tension Insanity,
published in 1874. He also coined the words ‘verbigeration’ and
‘symptom complex’ and later introduced the term ‘cyclothymia’ when
writing about circular insanity. Hecker, in 1871, described a rapid
mental deterioration occurring during puberty and called it
‘hebephrenia’.

Emil Kraepelin (1855-1926) is probably the roost outstanding
psychiatrist who ever lived. In the English-speaking world, where
much of his work has never been well kno^vn, there is a tendency among
some so-called ‘dynamic psychiatrists' to use his name as a synonym
for useless dry-as-dust pedantry in psychiatry. Nothing could be
farther from the truth. He qualified in 1878 and became an assistant
to Gudden in Munich. In i$8z he moved to Leipzig to work in
Flechsig’s clime, but left there farly soon to study experimental
psychology under Wundt In 1883 he published a Compendium of
Psychiatry which later was republished as a textbook in nine different
editions, the last appearing the year after his death. He was called to
the Chair in Heidelberg in 1891 and thereafter he developed his
classification of mental disease very rapidly, using Kahlbaum's two
principles of common symptomatology and common course of illness.
In 1893, in the fourth eefition of his textbook, he brought together
Morel’s dementia praecox, Heckcr’s hebephrenia, Kahlbaum’s catatonia,
and paranoid illnesses with deterioration (dementia paranoides) as
psychological degeneration processes. In the next edition of his book
in 1896, he called this group ‘processes of mental deterioration’ and
included them in a largpr group of metabolic disorders. In the sixth,
edition of his book he called these illnesses ‘dementia praecox’,
although by then he knew that these illnesses did not always occur in
adolescence and did not always lead to deterioration of the personality.

In 1893 he grouped depressh'c and manic illnesses together as
‘periodic mental illnesses’, but in 1899 he grouped together recurrent

l6 AN OUTLINE OF PSYCHIATRY

depressions, recurrent manta, and drcular insanity as manic-depressive
insanity. He claimed that these patients showed ndld mood abnormality
when well and from time to time developed severe affective illnesses.
He pointed out that, apart from clear states of mania and depression,
‘ mixed states ' occurred in which manic and depressive symptoms were
present at the same time.

Apart from his clinical work, he and his pupils carried out many
psychological experiments on patients and he can be regarded as the
founder of clinical psychology. In 1904 he returned to Munich as the
Director of the Psychiatric Research Institute and remained there until
his death.

Kraepelin’s great rival was Carl Wernicke (1848-1905), whose early
work on aphasia led him to look for discrete lesions as the cause of
mental illnesses. He did not accept Kraepelin’s division of the major
functional psychoses into two main groups, but tried to isobte many
different clinical pictures. Thiscarefuldciineation of different function^
psychoses was carried further by his pupil Karl ICleist (1879-1960).
Wernicke explained all psychiatric phenomena in terms of 'sejunction’,
viz., the breoldng of connexions bettveen different centres in the brrin.
He was the first to use the term 'autochthonous ideas’ and to differentiate
between disorders of impressibility (registration) and retention in
memory disorders. He also defined over-valued ideas and distinguished
between primary delusions and explanatory delusions.

Karl Bonhoeffer (1865-1948), Wernicke’s most outstanding senior
assistant and later Professor of Neurology and Psychiatry at Berlin
University, investigated the mental disorders associated with ooarec
brain disease and in 1910 published his classic monograph in which he
showed that on the whole the type of mental disease produced by
coarse brain disorders was dependent on the site, extent, and tempo of
the morbid process rather than on the specific nature of the brain
disease.

Before turning to the problem of the neuroses we must consider the
last of the great German-speaking psychiatrists, Eugen Bleuler
{1857-1939). He svas the first clinical psychiatrist to apply Freud's ideas
to the study of psychotic symptoms. He did this \vith his assistant,
C. G. Jung, who himself carried out verbal assodatJon experiments on
the psychologically ill. In 1911 Bleuler wrote his classic monograph
Dementia Praecox, or the Group of Schizophrenias. He coined the word
‘schizophrenia’ in order to get away from the implications of the term
‘dementia praecox’, m., that the condition always occurred in
adolescence and led to intellectual Imprirment. He used the term
‘schizophrenia’ because he believed tiat the functions of the mind
were split off from each other tn tlus disease.

HISTORY AND DEVELOPMENT

17

THE DEVELOPMENT OF PSYCHOTHERAPY AND THE
THEORIES OF THE NEUROSES

Hypnotism. — Hypnotism and su^estive psychotherapy have been
used from time immemorial. In the late eighteenth century
Franz Anton Mesmer practised hypnotism, which he called ‘animal
nu^etism’. He made exaggerated claims, ^vas to some extent a
charlatan, and brought the subject into disrepute. Later, in 1837, John
Elliotson (1791-1868), Professor of Medicine at University College,
London, practised hypnotism in University College Hospital. This
caused so much resentment among the physicians and surgeons there
that he ^\’as forbidden to practise hypnotism within the hospital, and
resigned in protest.

James Braid (1795-1860), a Scot who practised in Manchester, coined
the term 'hypnotism*. He showed that animal magnetism and similar
theories were nonsense, but that the phenomena were real,

Liebault (1823-1904) was a family doctor in Nancy who used
hypnosis to treat his patients. Later Professor Bemheim taught
hypnotism In the same to^vn.

J. M. Charcot (1825-93), the founder of modem neurology, was
Professor of Pathological Anatomy In Paris from 1867 and was
appointed in 1882 to a Chair in Diseases of the Nervous System,
specially created for him in the University of Paris. He was very
interested in hysteria and h)'pnotism and can be said to have made the
latter a respectable subject. This French school of neurologist-
psychotherapists produced many outstanding psychiatrists, including
Pierre Janet-

Freud. — Sigmund Freud (1856-1939) was interested in mild nervous
disorders, and in 1885 he studied under Charcot in Paris and also visited
Bemheim in Nancy. It was when Freud saw a case with Bemheim that
he first had an inkling of the idea of the unconscious.

*' Freu d had practically no training in psychiatry and this tvas at one
and the same time his strength and his weakness. At this time neurotic
illnesses were regarded by most psychiatrists as constitutional disorders
mainly due to inherited predisposition to degeneration. This view n'as
clearly expressed by J. L. A. Koch (1S91) in his monograph The
Ptychopathic Inferioritiet. Freud, following the Nancy School, regarded
the minor nervous disordeis as illnesses susceptible to treatment. He
was at first a neurologist and his investigations into aphasia and infantile
hemiplegia were fundamental contributions to this speciality. In the
course of his work he met with many mild non-organic nervous
disorders, which at first he tried to treat with hjrpnosis. He found that
this was not of much use, since the parient tended to forget any material
which was recalled during hypnosis.

l8 AN ODTLINE OF PSYCHIATRY

He developed the technique of psychoanalysis, in which the patient
was encouraged to allow his thoughts to proceed without any consdous
direction. It was assumed that the thought would then be directed by
unconscious processes and important material would emerge, which
would be responsible for the patient’s symptoms. By bringing thb
unconsdous material into consdousness the patient would be relieved
of his symptoms. Gradually Freud realized that this simple idea of a
neurosis as due to some hidden conflict in the unconscious u-as a gross
oversimplification. He then developed his theory of infantile sexudity
and the development of the sexual drive or libido during childhood.
DifHcultics in family relationships and constitutional factors led to
conflicts at certain points in childhood sexual development, and
reactivation of such conflicts by disappointments later in life produced
neurosis {see p. 28). Later, Freud and his followers realized that in
some individuals the mental disorder could be regarded more as a part
of a total character abnormality and called such states ‘character
neuroses’. Freud and his followers popularized psychotherapy and
helped untold nurabers of neurotics directly and inchrectly. Howwer,
they tended to overlook the simple fact that the psychological detennina-
tion of a symptom is not necessarily the same as the causation of the
symptom. Or, to put the problem in another way, what determines the
content of the symptom is not necessarily iu cause.

Two of Freud’s early pupils, Alfred Adler (1870-1937) and C. G.
Jung (1875-1961), disagreed with him and formed separate schools of
individual and analytical psychology {see pp. 30-32).

THE DEVELOPAiENT OF PSYCHIATRY IN
BRITAIN AND THE U.SJL

The outstan^ng British contributions to psychiatry were the humane
care of the insane and the 'non-restnint' movement. In clinical
psychiatry Anglo-American medicine has contributed little.

John Haslam (1764-1844) descrilwd a case of G.P.I. in his
Observations in Insamiy in 1798. Pinel thought very highly of this
work and in his o^vn book Sur V Alienation Mentale, published in 1800,
he refers to Hasfam's work more than to any other author. Haslam was
Apothecary to Bethlem Hospital; in other words he was responsible for
the day-to-day care of the patients. Unfortunately, his excellent clinical
knowledgewasnot coupled with a zeal for humane care. In 1816 he was
dismissed from his post owing to riie scandalous state of affairs in the
hospital, although, of course, he was not fully responsible, but was
obliged to carry out the instructions of the ph)’sidan Monro, who was
also dismissed.

HISTORY AND DEVELOPMENT tg

J. C. Prichard (1786-1848), who introduced the term ‘moralinsanity’,
was physician to the Bristol Royal Infirmary, a pioneer in the field of
ethnology, and a man of great erudition, but he added nothing but
confusion to psychiatry.

In Scotknd, Andrew Duncan, Professor of Medidne in Edmburgh
University, was responsible for the foundation of the Royal Edmburgh
Asylum, Momingside, the foundation stone of which vm laid in 1809.
In the early twenties of the nineteenth century Sir Alexander Morison
tried to establish a Chair of Psydiiatry in the University of Edinburgh,
but failed. He had studied with Esquirol in preparation for his psychia-
tric career and after his failure to establish a Chair he practised in
London. However, he gave a systematic course of lectures in Edinburgh
in 1823 and continued to ^ve an annual course of lectures until 1852,
when they were taken over by Dr. David Skae (1814-73) under the
aegis of the Royal College of Physicians of Edinburgh. In 1879
Sir Thomas Clouston was appointed as the first lecturer in the University
of Edmburgh and first lecturer in Mental Diseases and continued the
systematic lectures on mental illness. Thus, in Edinburgh, psychiatry
has been taught systemadcally from 1823 to the present day.

David Skae, Physician Superintendent of the Edinburgh Royal
Asylum from 1846 to 1873, was a firm believer in the physical basis of
mental disease and classified it into twenty-five groups according to its
supposed aetiology. He was a first-rate teacher and an inspiring chief.
No less than fifteen of his assistants became medical superintendents of
the new asylums which were established in Britain during the middle
of the nineteenth century. He rm the founder of the Edinburgh School
of Psychiatry, wtdch was the only psychiatric postgraduate teaching
centre in Britain until the Maudslty^ Hospital opened in 1922. His
most outstanding pupil and successor was T. S., later Sir Thomas,
Clouston (1840-1915), who was an exc^cnt teacher and clinician. His
book Clinical Lectures on Menial Diseases ivas the last great pre-
Kraepelinian textbook. He described juvenile general paresis and
‘ adolescent insanity*. He believed that Kraepelin’s ‘ dementia praecox*
ivas merely another name for his ‘adolescent insanity’, but he did not
appreciate that while he was classitying according to the age of onset,
Kraepclin was basing his classification on the symptoms and the course
of the illness.

Dr., later Professor,. G. M. Robertson (^1864-193,2) succeeded
Clouston as Lecturer in Mental Diseases and Physician Superintendent
of the Royal Edinburgh Asylum, the name of w hich was changed to the
Royal Edinburgh Hospital for Mental and Nervous Disorders in 1910.
He campaigned for the hospitalization of asylums and was one of the
first psychiatrists to introduce the twenty-four-hour-a-day nursing of

20

AN OUTLINE or rSYCHlATRV

acutely mentally ill male patients by female nurses, when he tras
Physician Superintendent of Stirling District Asylum. It was largely
due to his efforts that Jordanbum Nerve Hospital was opened in 1929 as
a public hospital for mild nervous diseases, which was quite outside the
lunacy acts, so that patients could be admitted and discharged without
any legal formality.

In London, Bethlem Hospital improved as the nineteenth century
wore on, and came under the direction of Geoige Savage, an
enlightened man and a good clinician. The Retreat came under the
direction of Daniel Hack Take, the great-grandson of William Tuke,
the only psychiatrist produced by the family of the man who pioneered
the humane care of the mentally ill.

Henry Maudsley (1835-1918) was an outstanding psychiatrist in
private practice in London in the late nineteenth and early ttventieth
centuries. He gave a large sum of money in order to found a univenity
teaching clinic in London. This led to the foundation of the Maudsley
Hospifcd, which is now associated with the Institute of Psychiatry of the
University of London. Maudsley was sceptical of most forms of
treatment current in his day. He divided mental illnesses into affective
and ideational groups. Unfortunatdy, the secondary delusions produced
by affective psychoses make such a divduon unworkable, since it has no
prognostic v^ue.

The most iniluential psychiatrist in the English-speaking world in
recent times was Adolf Meyer (1866-1950), a Swiss, who became
Profes«>r of Psychiatry at the Johns Hopkins University, and Director
of the Henry Phipps Clinic at the Johns Hopkins Hospital in 1910.

He regarded mental illness as a reaction of a person to environmental
difHculties, so that when faced with a patient the psychiatrist should
ask the following questions: (i) What arc this person's available
'resources? (2) ^Vhat are his faults and failings? (3) Wliat are his
assets ? (4} What was he like at bis best ? {5) How can his various
diffcullies be modihed ?

He stressed the need for a longitudinal study of the life of eacli
patient because it would help in prognosis, diagnosis, and treatment.
All possible factors — social, environmental, se:tual, and somatic — must
be conridered in relation to the life of the individual. A complete
estimate of potential assets is essentia! for adequate treatment and
prognosis. While he believed that the functional psychoses probably
had an organic basis, he was convinced that in sucli illnesses all factors
relevant to the patient’s illness must be taken into account in treating
the patient. This was in sharp contrast to many German psychiatrists,
who, believing that schizophrenia and manic-depressive insanity were
due to brain disease, did not treat patients except symptomatically.

niSTORT AND DEVELOPMENT

21

He appreciated the value of Kracpelin’s classification and espedally
his delineation of manic-depressive insanity and mixed states. However,
Meyer felt that Kraepelin’s system was too rigid and allowed the
unwary to neglect the role of the patient’s life situation in the causation,
continuation, and treatment of the illness. He welcomed Freud’s
dynamic approach, but felt that his views were too narrow and that
the emphasis on infantile sexual de\’elopment led to a neglect of other
important factors.

He campaigned for the improvement of the State hospitals in the
United States and also for hu manizin g the laws relating to institutional
care of the insane. He encouraged the growth of psychiatric social
work and occupational therapy.

Meyer tried to strike a balance between the two extreme attitudes ; on
the one hand, the patient as a mere spedmen of the given disease, and
on the other the patient as a unique individual reacting to a unique
situation in a unique way. With his solid background of German
psychiatry, neuropathology, and neurology he was able to see both the
wood and the trees. Unfortunately, most of his pupils lacked this firm
background and could not see the wood for the trees. They blurred the
boundaries between different disease entities and tried to understand
everything In terms of the individual and his environment. It is not
surprising that many of his younger pupils turned to psychoanalysis to
find a sure and certain doctrine in place of the rather vague concepts of
Meyerian ‘psychobiology’. Nevertheless, Meyer’s emphasis on the
individual and his assets tvas a salutary counterweight to those
psychiatrists who were only able to see the patient as suffering from a
disorder of the brain and were not able to sec the individual as a whole,
because their vision was obscured by the cerebral cortex.

Meyer’s influence on the English-speaking world was immense; most
of the leading British and American psychiatrists have at some time
studied at the Henry Phipps Clinic with Meyer.

DEVELOPMENTS IN TREATMENT

The Malarial Therapy of GJ*J. — ^The year 1917 is one of the
most important in the history of psychiatry, because in that year
Wagner-Jauregg, Professor of Psychiatry in Vienna, showed that
malaria could cure G.P.I. 'This was the first successful treatment of
a mental disease by physical means and raised great hopes for the
Aitirre.

Insulin Coma Therapy. — Sakel of Vienna introduced this treatment
following the successful use of insulin in the treatment of withdrawal
symptoms in drug addicts. He published his results of insulin coma
therapy in 1933. This treatment is falling into disuse and was never

22 AN OUTLINE OF PSYCHIATRY

subjected to a reasonable controlled trial. One or two fanatical believers

in the treatment still constitute a hazard in postgraduate examinations.

Convulsion Therapy. — About a.d. 45 Scribonius Largus, a Roman
physician, recommended that as a cure for a headache the Mediterranean
torpedo fish should be placed across the brows of the sufferer. This
fish develops an electrical potential of 100-150 volts. In the late
eighteenth and the nineteenth centuries there are scattered references to
insanity being cured by fits induced by large doses of camphor.

After the isolation of schizophrenia the belief that schizophrenics did
not suffer from epilepsy was expressed by many German psychiatrists.
Tlus was sometimes expressed in another tvay, i.e., schizophrenia and
epilepsy are opposite diseases. Working on this theory, von Meduna of
Budapest decided in 1933 to give schizophrenics epilepsy. He used
intramuscular injections of 20 per cent camphor and some of his
schizophrenics recovered. However, since camphor was uncertain in its
action, it was suggested to him that an artificial convulsant, penta-
methylenetetrazol (cardiazol), be used Instead. This treatment was then
widely used in schizophrenia.

Ugo Cerletti, a neuropsychiatrist and neuropathologist, had for many
yean investigated the effect of electrically produced fits in dogs in an
attempt to determine whether the changes found in Ammon’s horn in
epileptics were primary or a secondary effect of the anoxia during fits.
His collaborator, Bini, took part In this work and devised the electrical
apparatus. After von Meduna introduced convulsive therapy Cerletti
thought that electrically produced fits would probably be just as effective,
but he was deterred by reports that passage of an electric current through
the human head was fatal. Shortly after he was called to the Chair of
Psychiatry and Neurology in Rome, he was told that pigs were killed
by electricity in the Rome slaughterhouses, but he found that the pigs
were stunned by the passage of eicctridty through the head and then
the throat ^vas cut. He obtained permission to kill pigs by electricity
and found it was only possible to do this if the current passed through
the chest, but not if it passed through the head. He therefore felt
justified in passing an electric current through a patient’s head in order
to produce a fit. He did this in 1938 and found it to be an effective and
safe treatment.

As convulsive treatment became widely used it was realized that it
was a much more effective treatment for depression than for schizo-
phrenia.

Leucotomy (Lobotomy), — In 1874 Leopold Goltr, of Strasbourg,
reported that large ablations of the cerebral hemispheres in dogs led to
striking changes in behaviour. G. Buickhardt, medical director of a
small Swiss mental hospital, inspired by this work of Goltz, carried out

niSTOBV AND DEVELOPMENT 23

ablations of the temporoparietsi cortex in four agitated mental patients,
wth improvement in only one case. The publication of his results led
to a storm of criticism of his unethical behaviour.

At the International Congress of Neurology in 1935, Fulton and
Jacobsen described the behaviour of chimpanzees after ablation of the
frontal cortex. Unlike normal chimps, these animals did not become
upset when they failed on psychological tests and did not develop
‘experimental neuroses’ when over-tr^ned. This led Egas Moniz to
persuade his neurosurgical colleague Almeida Lima to destroy the
connexions of the frontal lobes in mentally ill patients. This treatment
was successful in anxious and tense patients. Lima and Moniz published
their work in 1936. This was followed by the work of the Americans,
Freeman and Watts, a psychiatrist and a neurosurgeon, who produced
a standard technique for severing the a>nnexion 5 of Ac frontal lobes with
the thalamus by inserting a brain needle through a burr hole made in
relation to certain landmarks on the skull. Since this time the operation
has been modified by many different neurosurgeons. It was valuable
in the treatment of tense, anxious, chronic depressives, schizophrenics
with torturing persecutory delusions and troublesome hallucinatOTy
voices, and severe, chronic, obsessional states. However, since the
introduction of the phenothiazines and the thymoleptic drugs, it is now
mainly used in the last group of illnesses.

The Modern Drugs, — Amphetamine was introduced for the treat'
ment of narcolepsy in 1935 and tvas later used In psychiatry as a
euphoriant.

Reserpine, the active prindple of the Indian plant Raimolfia
serpentina, tvas introduced in the early fifties for the treatment of
disturbed schizophrenics, although it had been used in the treatment of
mental disease by the indigenous practitioners of India for centuries.

The phenothiazines were introduced into medicine as antihistamlnics,
but it was soon realized that they tended to produce d^o^V8iness. This
led to the use of chlorpromazine as a tranquillizer in mania and
schizophrenia. Many other phenodiiazine compounds have since been
used. More recently, compounds resembling the phenothiazines
(amitriptyline and imipramine) have been shown to be antideprcssives.

In 1951 isoniazid was found to be an effective antibiotic in tuber-
culosis and to have a euphoriant side-effect. Later, iproniazid, an
isomer of isoniazid, was found to be a good antidepresslve. As this
drug tends to produce severe jaundice, other drugs were introduced
which, like iproniazid, inhibited the activity of mono-amine oxidase.
The pharmacology of the antidepresslve drugs Is now such a rapidly
expanding field that it is not ea^ to keep up with it.

24

CHAPTER in

THE SCHOOLS OF PSYCHIATRY
PSYCHOANALYSIS. FREUD AND HIS PUPILS

Psychoanalysis was originally used to designate the technique of free
association which Freud used in psychotherapy. Later it also came to
mean the theory which Freud constructed to explain the material which
emerged in psychotherapy. This can be considered from three different
points of view: (r) The theory of libidinal development; (2) The theory
of mental structure; (3) The economics of the mental dynamics.

The Unconscious.— Freud’s theory of the unconscious must be
discussed first. Originally he divided the mind into the conscious and
the unconsdous. The latter condsted of the representations of the
instinctual forces which were always striving for expression in conscious*
ness and also representations which had been conscious, but because of
their conflict with the person’s general attitudes had been unconsciously
forced into the unconscious or repressed.

Freud called the direct psychological expression of the instinctual
drives the ’primary pro«ss’ and pointed out that it was illogical and
disregarded such concepts as space and time; it was even possible for
two contradictory ideas to be present in the primary process at the same
time. This unconscious thinking tends to be pictorial, using words
without regard to their meanings, so that displacement, condensation,
and symbolbation occur. These are defined as follotvs: —

1. Displacement . — An idea which has something in common with
another is used instead of this second idea.

2. Condenrcljofl.— Two ideas with common features are condensed
into one.

3. SymSofealjOTi.— Feeling and drives are expressed in terms of
sjTnbok which may be personal or well kno\vn in the person’s culture.

The Structure of the JSiind. — Finally, Freud divided the mind into
three d3mamic systems: the id, the superego, and the ego.

1. The Id . — ^This is the fundamental source of all psychic energy,
since it consists of all the instincmal needs striving for fulfilment. It
mcTudes the mstmet of aggression as well as the sexuaf mstihct.

2. The Superego . — Roughly this is the conscience. In the Oedipal
stage (t« p. 26) the child id^tifies with his parents and incorporates

THE SCHOOLS OF PSYCHIATRY 25

their standards of right and wrong. This introjected parental image
acquires energy from the id and forms the superego, which is partly
unconscious. Since the parental im^e, which the child of 4 or 5 years
of age has, is capricious, illogical, and even destructive, the superego
may show these traits.

3. The Ego. — This has the task of balandng the demands of the real
world, the id, and the superego. It has no energy of its own and has to
borrow energy from the other two systems.

This structure of the mind develops pcnpoim with the development
of infantile sexuality and the ability to relate to objects.

The Instincts and Libidinal Development. — At first, Freud
derived all instinctual drives from the sexual instinct, but later he
claimed that there were two major instincts — Eros, or the group of
self-preservation drives, and Thanatos, or the self-destructive, aggressive
group of drives. Most of his followers accept the idea that the aggressive
drives carmot be entirely derived from the sexual instinct, but do not
accept the self-destructive Thanatos. The instinct, which has a
somatic basis, is the main source of p^hic energy, and is called the
libido.

^VheR Freud used the words ‘infantile sexuality' and referred to the
infant having libidinal satisfaction, he was using the word ‘sexual’ in a
very wide sense, to include all kinds of pleasure that the child obtains
from his bodily sensations.

As the child develops, Its activities at different stages of its develop-
ment are focused on different mucocutaneous junctional areas of the
body. Thus there are the oral, anal, and phallic stages of libidinal
development. The infant desires gratiScation of the instinctual needs
connected with the given stage. If these needs are under- or over-
gratified, then the conflicts usually present at the particular stage are
not resolved. The child passes on to the next stage, but a weak spot in
the libidinal organization is left behind, which may allow the reactivation
of the conflicts at this stage under stress in adult life. This is a fixation
poi nt. Freud also believed that constitutional factors might be partly
responsible for the formation of a hxatlon point. The stages of
development are: —

1. Primary Narcisttsm. — ^The neonate cannot distinguish between
himself and his environment and is unable to relate to objects. He gets
attention when he is dirty or hungry by crying and the regular associa-
tion between his actions and the response of the environment leads to a
sense of omnipotence and a belief that he has unlimited powers over his
environment.

2. The Oral Stage. — ^This begins at birth and can be divided into: —

a. The early oral ttagei Here the infant gets pleasure from sucking.

26 AS OVTLIHB OF FSTCUSATRY

b. The late oral stage: Teeth hate now appeared and the child gets
pleasure from biting. Aggressive impulses can be expressed by biting
and this stage is therefore called the oral sadislie stage.

The wrld now consists of objects which can or cannot be «valiowed;
the only object relation possible at this stage is therefore incorporation.

3. The Anal Stage. — This begins in the second year, when the child
gets pleasure from defaccation. Passing and retaining faeces are easily
connected tviih aggression, so tliat this is the anal sadistie stage. This
stage can be divided into:— •

a. The early anal stage: Here the child gets pleasure from eliminating
and pinching off the faeces.

b. The late anal stage: Here he experiences pleasure from retaining
faeces. Tims the child behaves in a contradictory way, as he wants both
to retain and expel his faeces. Thus ambivalence (tee p. 54) is associated
with anal eroticism. Partial love of objects with ambit'alence is possible
in this stage.

4. The Phallic Stage. — Ily the fourth year the libido is centred on the
genitalia, and sexuality is connected with a special love object. The
little boy loves his mother, regards father as arivaJ. and wshes him dead.
This is the Oedipus complex. The boy attributes to his father the
same sort of tviahes that he himself has tmt'ards father. He realizes the
anatomical difference bettv-een the sexes and regards females as
castrated males, so that it seems possible to the boy that his father’s
supposed aggression totvaids him might take the form of castndon.
This Crisis is solved by the boy identifying tilth his father and intro*
jecting parental attitudes as they appear to him, i.e., the superego is
formed. In the girl sexual sensation is experienced in the clitoris, but
she soon realizes that she has no penis; this gives rise to penis envy and
she tvants to get a penis from her father. The penis is equated ivith a
child and she now loves her father and wishes her hated rival, her mother,
dead. This is resolved by identification with the mother. In both sexes
the Oedipal situation is resolved by identification with the parent of
the same sex, or partially dealt with and then repressed.

5. The Latency Period. — Sex drii'c subsides after the sixth year and
reappears at puberty.

The Economics of the AUnd. — ^The ego has to control the
unacceptable instinctual drives in such a way as to suffer the least
discomfort and to achieve the greatest possible degree of coherence
with the minimum amount of effort This is done by defence
mechanisms which (a) emerge at different stages of libidinal develop*
wwwf, (b) Viaxt dvSxvxwt itUtvowsbvps vritiv vasy vn

flexibility; (d) may be more often assodated with one or another of the
instinctual drives. These mechanisms are: repression, reaction

THE SCHOOLS OF PSYCHIATRY 27

fonnatlon, displacement, aim inhilntion, sublimation, projection,
introjection, identification, isolation, undoing, and regression. These
will now be discussed individually, but they are usually all at work at
the same time.

Repression. — All ideas have a tdiai^ of energy or cathexis which
produces the emotion appropriate to the idea, when the idea becomes
conscious. Some ideas give rise to amdety when conscious because the
associated instinctive drive is not approved of by ego or superego. If
this occurs, the unwanted idea is unconsciously pushed out of conscious-
ness by the mechanism of repression in which there is a withdra^val of
cathexis from the idea and a charging of opposing ideas with cathexis,
so-called ‘ojunter-cathexis*. The repressed idea may obtain indirect
representation in consciousness, but if this causes anxiety it may be
repressed as well. This is secondary repression.

Reaction Formation. — ^The disturbing ideas are kept unconscious by
the presence of the opposite ideas in consciousness. Thus excessive
prudery can be a reaction formation against powerful sex drives.

Displacement. — ^Thc cathexis is transfened from the unacceptable
ideas to other associated ideas which can appear in consciousness
tvithout causing anxiety. Thb is a more flexible means of defence than
reaction formation.

Aim Inhibition. — ^The aim or goal of the instinctive drive is modified,
but the original drive is satisfied to some extent. Thus a desire in a child
for sexual relations with a parent may be changed into an attitude of
love and respect in which there is no overt sexual element.

Sublimation.-^-The original aims of a drive are permanently and
totally changed and are gratified by the new aim. Thus infantile sexual
drives are desexualized and the libido is transferred to a new goal-
directed activity which is decided 1^ the ego and approved by the
superego.

Prc^'eclion. — Repressed ideas are attributed to others. The unpleasant
affect which such ideas would arouse in consciousness is blamed on the
ideas and attitudes of others.

Intrc^eciion. — The object is, as it were, ingested by the mind, so that
the psychic energies of the ego appear to be organized as if they were
under the control of the introjcct.

Identification. — ^The person adopts the ideas and attitudes of an
cfejtct, tut %’aVi a nkatiow vriVh the which, uulikt the

introjcct, does not function only as if it were part of the ego.

/sofation. — The impulse to action, thought, or act is isolated from
the associated affect and the wider associations connected with it. The
thought, for example, is conscious without the distressing associations or
affect. This defence is found in obsessional neuroses.

28 AN OUTLINE OF PSYCHIATRY

Undoing. — ^The disturbing tbou^t or action is allowed to occur and
is then folimved by the oppo»te thought or act, which cancels out the
effect of the first thought or act in a magical way. This mechanism is
especially seen in obsessions and compulsions.

Regression. — ^The mind returns to an earlier stage of libidtnal or ego
organization, so that there are both libidinal and ego regressions. The
degree of regression depends on the fixation points (rre p. 25). Regression
in normals occurs in dreams, daydreams, and fantasy. Fantasy is a
means of defence since it often allows the ego to balance the demands
of the id and the environment.

Introversion.* — This occurs when a person withdraws from
environmental contacts and indulges in excessive fantasy. This is
usually followed by marked regression.

The Freudian Theory of Neurosis. —

1, Release of Libido. — A loved object is lost, e.g., a friend or relative
dies, and this means that the libido invested in that object is set free.
This causes regression and reactivation of the conflicts at the fixation
points. A neurosis occurs if the amount of free libido is excessive and
if the infantile conflicts at the fixation point were not solved or partially
solved by pathological mechanisms.

2. Failure of Repression. — Unconscious ideas, related to the
reactivated infantile conflict at the fixation point, acquire enough
psychic energy to force themselves into consdousness and give rise to
anxiety. With this failure of repression, other defence mechanisms
such as displacement and projection come into action in order to
camouflage the ideas painful to the ego. This leads to a symptom
which is a conscious but distorted expression of the unconsdous
conflict. The major defence raeebanism at work in any given mental
illness depends on the stage of libidinal development at which the
fixation point occurred.

Character Neurosis. — Freud finally realized that in many neuro-
tics the defence mechanisms had modified the ego and superego,
produdng a character disorder. In this case the patient acts out
his difficulties and is suffering from a character neurosis. It is,
therefore, possible to refer to the character in terms of the fixation
point, so that one can have an anal character or an oral character, and
80 on (see p. 73).

Freud’s Theory of Dreams. — As Freud and his followers often
use dreams as a starting point in analysis, Freudian dream theory is of
considerable importance.

* This should not be confused with the Jung'ian concept of introveraJon
(lee p. 3J).

THE SCHOOLS OP PSYCHIATRY 29

1. Manifest and Latent Content. — Freud believed that the dream as
it %vas reproduced in the «aldng state (its manifest content) could be
traced back to its origins (latent content). The change from latent to
manifest content %vas the product of dream work in which condensation,
displacement, and symbolization played a great part. One can always
find in the latent content materid from the previous day and from
childhood.

2. The Dream as ‘ Wish' fulfilment*. — Freud claimed that the dream
was always the fulfilment of a ^vish, although, because of the effect of
the dream work, the wish might be grossly distorted. The dream was
an attempt on the part of the unconscious to express this wish fulfilment
and it was represented in a pictorial way, since this is the primitive way
of thinking in the unconscious (see p- 24). Those unconscious wishes
which cannot be tolerated by the conscious are rendered relatively
innocuous by the dream work.

Klein’s Modificatioos of Freudian Theory, — Klein believed that
mental organization developed rapidly in the first year of life and that the
ego existed from birth. The neonate experiences being wet and ^rty as
persecution, but when his wants are satisfied he has the feeling of love.

The Paranoid Position. — The mother is at first the child’s whole
world and his hate and love are directed solely towards her. The ego
protects itself by the mechanisms of introjection, projection, and
splitting. Thus object relations exist from birth. The lack of cohesion
of the early ego leads to a splitting of impulses into good and bad; in
particular the mother image is good and bad. In the first 3-4 months
the chief features of mental life are feelings of omnipotence and
persecution and the mechanism of splitting. This Is the paranoid
schizoid position.

The Depressive Position. — The integration of the ego increases and
the splitting decreases, so that the good and bad aspects of introjects
and objects can be synthesized. The superego begins to function at the
end of the fifth and sixth months. The child fears the effect of his
aggressive impulses and greed on his loved objects. Since a wish and an
act are the same thing to him he feeb guilty, and feels compelled to
make some compensation for the barm he believes he has done. Thb
leads to an anxious depression or the depressive position. This is slowly
worked through as the child’s knowledge of the world increases.
Depressive and persecutory anxieties are never completely mastered
and may return when internal or external pressures become intense.

The fundamental criticism of the Klrinian views is that they assume
a degree of perceptual organization and intellectual ability which is not
in keeping with the facts about the infant’s abilities in the first year of
life.

30 AN OUTLINE OF FSYCniATRY

ErUison’s Views on the Latency Period and Adolescence. —
During the Oedipal stage the child learns to trust others and tliis allows
him to enter the wider cxtmfamilial society with confidence. He then
teams the roles and skills w hich will prepare him for an aaive member-
ship of his society in adult life.

The phj-sical changes at puberty produce sex drive and rcatvaken the
Oedipal complex. The adolescent has two major problems: (i) Dealing
with sex drive; (a) Clianginghis relation to bis parents from one of love
and dependence to one of love and independence.

The person must find hit identity. Ego identity is made up of those
comprehensive gains which the person must base derived from all his
pre-adult experiences by the end of his adolescence in order to be ready
for the tasks of adult life.

l*lie adolescent has a conflict between identity and identity diffusion
w hich may reactivate conflicts at earlier stages of development and give
rise to the variegated symptoms of the adolescent crisis.

Other Deviations from Freud. — Space forbids discussion of the
views of Homey, Fromm, Hartmann, Sullivan, and others. The
interested mdcs should consult the review-s of their work which ore to
be found within books in die reading hst.

ALFRED ADLER AND INDIVTOUAL PSVCIfOLOCY

The ideas of this worker are not as well organized and coherent as
those of Freud and tend to be rather superficial oveirsimplifieations.

De\'elopraent of the Child. — ^The cMld’s basic problem is helpless-
ness and the inferiority which it engenders. All human activity is
motiwted by a ‘will to power* or a striving to pass from the inferior
position tn a superior one. The developing normal child faces his
problems in a confident realistic way and constructs a goal or ideal
self with the material provided by his physical inheritance and his
environment. Psychic activity is organized in terms of the child’s goal
and by the age of 5 years he has developed a life style designed to
achieve his goal.

Oz^an Inferiority. — A phpical defect of an organ or an imagined
defect may determine the individual’s life 8t)-le, because he may use it
as art excuse, or, in trying to compensate for it, he ovcrcompcnsatcs
instead.

Position In the Family. — Relalionsldps with sibs and parents are
tlie main moulding factors in the environment. Thus the spoiled child
becomes dependent and unrealistic, wliile the hated child becomes
aggressive and suspicious. Portion in the family is important The
eldest child Is a dethroned king, insecure due to criticism from above
and competition from below. 'Phe second child has the elder brother

THE SCHOOLS OF PSYCHIATRY 3I

held up as an example, so he become discouraged and defeated or
rebellious and ambitious. The youngest child wth no competition
from below is a weak person among the strong and may learn to deal
with others by guile and cunning.

Masculine Protest. — In Western society masculinity is considered
as strong and femininity as weak. A girl may react to the added
inferiority of being a femie by taking the male role or be very feminine
but efficient, dominating, and basically masculine in her general
behaviour. An adolescent hoy may realize that he has feminine attitudes
and make a masculine protest by becoming a tough, extroverted
‘he-man’.

Theory of the Neuroses. — The patient adopts a goal and a life style
which do not correspond with his potentialities and the total life
situation. The conflict Mth his environment threatens his ideal and
symptoms arise in an attempt to preserve his faulty attitude. Although
Adler rejected the unconscious, he believed that the patient ^vas only
partly aware of his goal and life style and consequently would be
unaware of the source of his symptoms.

a G. JUNG AND ANAUrnCAI. PSYCHOLOGY

Jung did not reject the idea of the unconscious, but regarded it as
composed of individual repressed material and the inherited collective
unconscious.

Personality Types? Extrovert versus Introvert.— The introvert
turns Ids libido inwards and lives more in his own inner life, while the
extrovert turns his libido outwards to the world around him, makes
relationships easily with others, and is active and confident. The
opposite attitude is to be found in the unconscious. The more
pronounced the conscious attitude the more marked the unconscious
one.

The Four Functions. — These help the person to orientate himself.
They are: sensation, intuition, feeling, and thinking. These work
in harmony in the normal individual and process the information he
receives, but if one function b exaggerated there is a personality type.
Sensation and intuition form one set of opposed pairs and thinking and
feeling form another. Thus sensation and intuition are dilTerent way’s
of dealing with perception, and thinking and feeling are different ways of
ryalualkg n jrlr, she ikwlinxis are p r nrcdo f xu in

consciousness, while the opposing pair are more important in the
unconscious.

The Persona. — ^This is the aspect of the self which is deliberately
presented to the enrironment. If it b too well organized, then attitudes
which do not fit in are repressed and conflict may occur. If it is badly

32 AN OUTLINE OP PSTCHIATRY

organized the environment will easily modify it and the person will feel

insecure because he is unsure of his role m life.

The Unconscious. — This is made up of a personal and a collective
part, in both of which ^mbols are used. Thought processes in the
personal unconscious are often the reverse of those in the conscious
mind. The ‘shadow’ is the reverse side of the consdous mind,
comprising all the unpleasant aspects of the conscious psyche. This is
partly collective as well as person^ and is often represented symbolically
as a devil or witch.

The Archetypes. — ^These occur in the collective unconscious and
each corresponds to some basic aspect of the individual’s existence.
The anima and animus are archet)'pe3 equivaTent to the 'souP of
primitive man. Every num has an unconscious anima or female soul,
while each woman has an animus or male souL Other important
archetypes are the tvUc old man and the great mother. The self may
appear as an archetypal image in the form of a small child, a
hermaphrodite, or a flower.

Theory of the Neuroses. — There Is a conflict between a conscious
tendency and a complex or an aflect*laden group of unconsdous ideas.
The attitude to life is one-sided, so that what could not be integrated
has been repressed. The complex may be due to childhood diSiculties
or a change in the life situation which renders previous attitudes non*
adaptive, A neurosis is not only an illness, but an attempt at adjustment
During psychotherapy the patient becomes a complete personality
and finds true self as an integral part of humanity. This is
‘individuation' and occurs when the analysis has helped the patient to
encounter and understand the different archetypes.

PAVLOV AND THE NEO-PAVLOVIANS
The Conditional ReQez (CR), — An inborn or unconditional
reflex (UCR) can be associated with a neutral stimulus by applying it
in conjunction with the natural stimulus which evokes the reflex. This
produces a condiuonal reflex (CR). The conditional stimulus (CS)
produces a focus of activity tn the brain and this links up with the focus
of activity produced by the unconditional stimulus (UCS).

The Cortical Analyser. — ^Tbe cerebral cortex analj-ses the incoming
stimuli and cormects them with the subcortical centres which mediate
the UCR. Inhibitory and excitatory processes can radiate over the
cortex, concentrate on one area, or induce the opposite activity in
cortical areas not previously affected. Inhibition often protects the
cortex and sleep can be regarded as widespread inhibition.

First and Second Signal Systems. — The CR is the result of the
ability to form temporary connexions, which is an important adaptive

THE SCHOOLS OF PSYCHIATRY

33

function, since it allows the animal to respond to distant environmental
stimuli and differentiate between them. This is the first slgr^ system.
In man a new kind of CS, the word, is effective, and this second signal
system allows of an even finer adjustment to the environment.

Types of Nervous System. — Strange results were sometimes
obtained during CR experiments, which led Pavlov to classify his dogs
according to the force, the equilibrium, and mobility of the processes
of excitation and inhibition. Four types of dog were isolated — a weak
inhibitory type, a strongly excitable type, and a strongly equilibrated
type which could show either marked mobility or inertia, and was there-
fore divided into lively and quiet types. Under stress all types of dog
broke down and had * experimental neuroses'. Three tyqjcs of nervous
activityr might produce these ‘neuroses’: (i) Ovcractivity of the ex-
citatory process; (2) Overactivity of the inhibitory process; (3) Undue
mobility of the nervous process.

Animal Neuroses. — These may be extreme excitability, extreme
inhibitability, or a phasic or hypnotic state. This latter has three phases:
equalizafion, paradoxical, and ultraparadoxlcal. In the equalization
phase all CS’s to the same CR have the same effect independent of their
nature and strength. In the paradoxical phase the strong stimuli have
a weak effect and vice versa. In the ultraparadoxical phase inhibitory
stimuli produce excitation and vice versa.

These 'neuroses' responded to rest, retraining, drugs, and sleep. In
some cases bromide was effective, probably due to intensification of the
inhibitory process leading to concentration of the excitatory one. In
others, caffeine was more effective because it intensified the excitatory
process. Barbiturate sleep was effective, but hypnotic sleep produced
by repeated monotonous stimuli was even better.

Human Types and Neuroses. — In man the UCR and the first
signal system when stimulated produce an immediate response
associated wth an autonomic response, which is therefore an emotional
response. The second signal system allows a rational evaluation of the
environment and corrects the emotional response of the first signal
system. This pves three personality ^es: (i) Average, in which the
activity of the UCR and the first signid systems is balanced by the
second signal system; (2) Thinker type, in which the second signal
system dominates; (3) Artist type, in which the CR and the first signal
system play the major role.

Neurosis b a general weakness of the nervous system, but the form it
takes depends on the type of personality. The average type develops
neurasthenia, the thinker psychasthenia, and the artistic type hysteria.

Evaluation. — The transposition of experimental findings in dogs to
human beings is alwaj’s dangerous, and in this case, in view of the

3

34 AN OUTLINE OF PSTCHIATIiy

extraordinary complexity of the human brain Compared with that of the
dog, it is like trying to explain the mode of operation of a television set
by concepts deduced from the functioning of a clockwork toy.

Some workers have compared the sudden change in the condition-
ability of dogs to the sudden changes in attitude which occur in religious
conversion, brain washing, and psychotherapy. It may well be that
some psychological phenomena may be due to fairly simple physiological
changes in the brain, and we psychiatrists are misled by a verbal
rationalization of a physiological phenomenon by our patients, so that
we allow the content to disguise Ac form.

35

CHAPTER IV

GENERAL SYMPTOMATOLOGY
INTRODUCTION

In this chapter individual symptoms mil be discussed in isolation, but
this is purely for convenience, because, although symptoms never occur
in isolation, it is helpful to have a clear idea of the separate symptoms
and their value in diagnosis. In order to do this, it is necessary to
consider the symptoms as disorders of different functions of the mind;
but since the organism functions as a whole, this is merely a convenient
fiction, useful for ordering facts. The symptoms of psychiatric and
allied disorders will now be discussed as disorders of; (i) Perception;

(а) Thought; (3) Memory; {4) Consciousness; (5) Emotion and Feeling;

(б) Intelligence and Personality; (7) Motor B^aviour; (8) Speech and
Meriting.

DISORDERS OF PERCEPTION

These can be divided into: (t ) Sense deceptions ; (a) Sense distortions.

X, Sense Deceptions.— These in turn consist of illusions and
hallucinations.

a. lllutions . — These are misinterpretations of a real stimulus, e.g., a
shadow is taken to be a man. The causes are; set or attitude, intense
emotions (normal and abnormal), and lack of perceptual clarity.
Illusions are therefore common in delirium since perception is poor,
anxiety and perplexity are prominent, and a paranoid attitude U usual.

The depressed, guilty patient may mishear what people are saying
and it may be difficult to decide at times whether the patient has illusions
based on set or is attributing hallucinatory voices to people in the
environment.

b. Hallucinations . — These are perceptions without an object or
mental impressions of sensory vividness without an adequate external
stimulus.

i. PseuJohalluanationsi Here the hallucination lacks the vividness of
a true percept and does not appear to be substantial and in perceptual
space. Hypnagogic and hypnopompic hallucinations, which occur on
fallingas 1 eepandwakinguprespectively,areu 3 ually pseudohallucinations
and are not uncommon in normals. Similar hallucinations are found in
fatigue, exhaustion, and sleep deprivation. It is usually said that these

36 AN OUTLINE OP PSYCIIIATIIY

hallucinations are most often vistial rather than auditory, but some
workers have found an excess of auditory hallucinations. Hypnagogic
and hypnopompic hallucinations may become very troublesome in
patients with lesions around the third ventricle. Pseudohallucinations
may o ccur in anv variety of psychosis and in h^-steria ,

ii. True hallucinations'. Here the hallucination has perceptual
clarity. They can be suggested to normals or may arise from self-
suggestion, e.g., someone expecting a telephone call may hear ring-
ing.

c. Causes of Hallueinattons . —

i. Affect'. Very depressed self-reproachful patients may hear
reproaching voices. This is a vivid ‘voice of conscience’.

ii. Delusions: The false belief leads to misinterpretation of the
environment and expected words may be iiallucinated.

iii. Suggestion: Hysterics may hallucinate and naturally say they see
things which fit in with their fantasy and their cultural background,
such as men, frightening faces, and so on.

iv. Disorder 0/ a peripheral sense organ: Ear disease or eye disease
may produce hallucinations, but often some central change is also
present. Negative scotomata occur in delirium tremens and may be
partly responsible for the visual hallucinations.

V, Sensory deprivation: If the amount of incoming sensation is
reduced to a minimum then hallucinations will occur after a few hours.
This may be an additional factor in producing hallucinations when there
is some disorder of the eye or car.

vi. Brain lesions: Focal lesions of the central nervous sjstem, lesions
in the brain-stem, midbrain, and cortex may cause hallucinations.
Temporal lobe epilepsy is often assodated xvith xnsual and auditory
hallucinations.

vii. No clear cause: Hallucinatory voices are very common in
schizophrenia but the reason is not dear.

d. Hallucinations oj Individual Senses . —

ij Hallucinations of hearing: These can be divided into: (a) Elemen-
tary, and (^) Organized hallurinations (halludnatoiy XTiices).

a. Elementary hallucinations: These consist of noises and music.
They occur in schizophrenic and organic psychoses.

p. Hallucinatory voices ( phonemes) : These may be dear, or undear
and vague. They may talk to the patient and give him orders— so-called
i mperative halluanations . The patient may feel obliged to carry out the
orders or may be able to ignore them. They may talk about the patient
in (bethiedpet^nand fnayeivngcreatxsamngcaninKntarj'oahisscts.
Usually they are abusive, but occadonally they are friendly and
reassuring. The abuse is commonly of a sexual nature, women being
called whores, etc., and men homosexuals and so on.

GENERAl- SYMPTOMATOLOGY 37

Sometunes the content is sensdess and may even contain neologisms
(see p. 47). Some patients can reproduce the content of the voices
without difficulty, while others can only give a very vague idea of what
the voices say. The patients’ attitude to the phonemes varies consider-
ably. Some complain about the content of the phonemes, but others
complain more of the phenomenon itself. In som e ca s^ the voices may
cease if the patient directs his attention to some form of occupation,
while in others the voices arc continuous and Interrupt all mental
activity, so that the patient is incoherent, dishevelled, and dirty. The
sudden onset of phonemes often causes intense anxiety and depression
which may lead to suicide. When the phenomenon becomes chronic
the patient may accept the voices with resignation or may continue to
protest about them, or, realiaing that others do not believe him, he may
deny hearing voices and only talk about them to someone whom he
trusts. pMients attrib ute their phonemes to vario us sources, such as
witchcraft, telepathy, radio, television, atomic rays, and so on. Some
claim that the voices are from real people in their environment and may
assault innocent bystanders from whom the voices appear to come.
Gedankenlautieerden and functional hallucinations are special kinds of
phonemes.

Gedankenlautwerdeni Here the patient hears his own thoughts spoken
aloud as he thinks them. In chronic patients this may take the form of
other people speaking his thoughts ^oud or replying to his thoughts
before he spe^ them. There is no accepted English term for this
symptom. The present author has used the term ' thought-echo’ for it.

Functional hallucinations-. Here the phonemes oidy^ oc cur if there is
some external source of noise. Thus these patients may hear voices
when the tap is running or may cease to hear voices when the external
auditory meatuses are blocked with ^vax or cotton-wool. This is not an
illusion, since both the noise and the halludnation are heard at the
same time.

Elementary auditory halludnadons occur in schitophrenia and
prganic psvchosgg.. Odd words may be heard in organic states but
continuous phonemes are not common. Depressives may hear
reproachful voices, but these arc somewhat repetitive and disjointed,
consisting of odd words and phrases reviling the patient or instructing
him to commit suicide. In schizophrenia the phonemes are usually
raoit TOntinwous and if they ttviVe the patient he usually itsents it,
whereas the depressive feels that the wices, which say such tUngs as,
‘Miserable sod’, 'Rotten bugger’, and so on, are making justified
reproaches.

jj. Hallucinations of visions These may be elementary, consisting of
fiasKes of light; or organized, in which case they may be organized

38 AN OUTLINE OF PSYCHIATRY

figures seen against the normally per«ived environment; or scenic,
when whole scenes are hallucioated. All varieties of visual hallucination
are common in organic psychoses, when consciousness is clouded, but
they can occur in acute and chronic sc hizophreni a. Small animals arc
often seen in delirium, espedalljr in delirium tremens. Usually they are
associated with extreme fear or terror. Scenic hallucinations are prob*
ably most common in epileptic attacks and psychoses. Sometimes a
memory appears with perceptual clarity, so-called ‘hallucinatory
flashback’. Some epileptics have visions of fire and religious scenes,
such as the Crucifixion.

Occasionally in organic states Ulliputian hallucinations* occur; the
patient sees little men and women. This is usually associated with
pleasure; for example, one patient with delirium tremens saw a German
band made up of tiny men playing on her counterpane, and enjoyed the
experience.

Heautoseopy (DoppelgUnger) is a special type of visual hallucination in
which the subject sees himself and realizes that it is he. This tends to
occur in lesions of the parietal lobes, which are most often due to
cerebral thrombosis. This probably accounts for the German folk-lore
belief that one sees one's Doppelgdnger shortly before death. Negative
Jieautoscopy occurs tvhen tbe subject does not see himself when he
looks in a mirror. This is also usually due to lesions of the parietal
cerebral corte.x. In internal heautoseopy the subject seea bis own
internal organs. This seems to be confined to French-speaking subjects.
The description of the internal organa » that which would be expected
from a layman acquainted with 3 butcher's shop.

Mass haUucinations: Some chronic schizophrenic patients see and
hear scenes of mass butchery and violence.

Extracampine Jialludnalitms: The person has a hallucination which is
outside the perceptual field ; for example, a patient sees a hallucinatory
object behind tus head, or hears a voice speaking in London when he
is in Edinburgh and is fully aware of bis rituation.

iiL IlaJludnctwns oj dfaetionz Hallucinations of smell occurin many
diflerent psychoses, but it is not always easy to be sure whether the
patient is compltining of a halludnation, an illusion, or a delusion.
Some acute schizophrenics and organic psychotics complain that they
are being gassed and can smell the poisonous gas. Some depressives
and schizophrenics are certain that they emit an unpleasant smell,
while others believe that they do not stink but that other people think
that they do. Attacks of temporal lobe epilepsy are often ushered in by
a hallucination of a very unpleasant smell, such as that of burning paint
or rubber.

iv. Hallucinations of taste. Halludnations of taste do occur, but
cannot always be distinguished from secondary delusions. Thus the

GENERAL SYMPTOMATOLOGY 39

schizophrenic feels utterly changed physically and mentally, which
leads him to assume that he is being poisoned.

V. Hallucinations of tactile sensation: Hallucinations of touch and, in
particular, the feeling of animals crawling over the body are not
uncommon in organic states. They are particularly well marked in
cocaine psychosis, where they are known as the ‘cocaine bug*.

Sexual hallucinatioris^can be regarded as a special variety of tactile
hallucinations. Some male schizophrenics complain that erections and
orgasms are forced on them and that semen is extracted from their
penises. Female chronic schizophrenics complain of rape and sexual
sensations; occasionally they have an almost continuous hallucination
of a penis in the vagina.

vi. Hallucinations of deep sensation: Some patients, usually schizo-
phrenic, have hallucinations of twisting and tearing pains and electric
sensations which may be expressed in a bizarre way. In the absence of
coarse brain disease bodily hallucinations clearly experienced as due
to external influence are schizophrenic in origin. However, care must
be taken to be sure that the patient really experiences the bodily
sensation as due to outside influences and is not saying that it is ‘as if'
this was the source of the sensations.

vii. Hallueinalions of vestibular sensation : Some patients, usually with
organic states, have vestibular sensations and have the experience of
flying through the air or being twisted and turned.

e. Reflex Hallucinations.— In normals synaesthesia is well known.
The person has a sensory experience in another perceptual field in
addiUon to the one in which the stimulus occurs. It is also possible in
normals to produce a visual hallucination of a flash of light by sounding
a tone immediately before the flash. ^Vhen this is repeated many times
it is possible to sound the tone and the subject wU perceive a light
when none has appeared. In some schizophrenics a stimulus in one
perceptual fleld produce a halludnation in another; for example, a
patient/Complains of pain in the chest when he sees the doctor put his
key in the lock of the ward door. This is a reflex hallucination.

/. Patient's Attitude to Halhicmations. — Occasionally in organic
states the patient is not troubled his hallucinations, but usually there
is terror and he may try to escape from his supposed persecutors; in so
doing he may injure or kill himself by jumping out of windows, etc.
Most hallucinating depressed patients consider the remarks justified,
but some blame their depression on (he persecution. In the acute
shifts schizophrenics are frightened by the phonemes and may attack
the alleged source. This attitude may continue in the chronic stage,
but many chronic patients are on the whole little troubled by their
phonemes and may treat them as old friends. Such persons often refer

40 AN OUTLINE OF PSYCHIATRY

to the phoaemes as ‘the voices’ and can distinguish them from real
voices.

Hallucinations arc, of course, only a part of an illness and the patient's
attitude is determined by the change in the personality produced by
the disease.

g. Hallueinatory Syndromes. — Schrdder described four common
hallucinatory syndromes; confusional, self-reference, verbal, and
fantastic hallucinosis.

1. Confusional halludnosis: Consciousness is clouded and visual
hallucinations are prominent, while auditory hallucinations, if they occur,
consist of music, noises, or odd words; connected sentences are rarely
hallucinated.

ii. Self-reference hallucinosis: The patient hears voices talking about
him. Often it is difhcult to dedde if phonemes are present or if the
patient is merely mishearing real conversations. He cannot give the
actual words used, but only a rough idea of what is being said.

lit. Verbal hallucinosis: Clear phonemes are heard, talking about the
patient, and he is able to reproduce their content accurately. The
phonemes are attributed to real or imaginary people or machinery.

iv. Fantastic hallucinosis: The patient reports weird fantastic
experiences, based on auditory, bodily, and visual hallucinations. It is
impossible to disentangle the hallucinations from delusions and
sometimes it seems that dream experiences are also involved.

2. Sense Distortions.—

a. Visual Distortions. £|yfmegafo/>«a.— Distortion of the retinal
image can be produced by lens abnormalities; thus, the astigmatic sees
objects too long in one axis and too narrow in the axis at right-angles.
Distortions of the image may also occur in lesions of the posterior
temporal and occipital lobes.

In micropsia objects in the visual held appear smaller or farther away
than they actually are. In macropsia or megalopsia the opposite occurs.
These terms have also been us^ to designate the size of objects in
hallucinations and dreams.

Micropsia can be produced by paralysis or disproportionate over-
activity of accommodation wluch produces a smaller image than would
normally occur with the same amount of convergence. Excessive
convergence out of relation to the degree of accommodation will
produce macropsia. Occasionally severe atropine poisoning causes
macropsia. Oedema of the retina \rill separate the rods and cones and
may produce micropsia, while scaniog of the retina will cause macro-
psia. These peripheral causes of dysmegalopsia are not very common.

Attacks of dysmegalopsia, usually with marked anxiety, may occur in
focal lesions, such as tumours of the temporal-ocdpital cortex and

GENERAL SYMPTOMATOLOGT 41

scars in the same region due to disease or injury. Similar attacks
occasionally occur as an aura or an equivalent of an epileptic ht, but
macropsia seems to be more common than micropsia in epilepsy.
Acute organic states due to alcohol, bromides, and infectious fevers
sometimes cause dysmegalop^ and If micropsia occurs Lilliputian
hallucinations are also usually present Dysmcgalopsia is, of course,
extremely common in psychoses due to mescaline and LSD {ite p. 206).
This disorder is sometimes seen in schizophrenia, hysteria, and disturbed
adolescents. In these illnesses the patient usually complains that people
look distorted, in particular that their beads are too small.

h. DistoTtiom of Hearing . — Localear conditions can cause hy perac usis,
while anxiety from any cause can increase sensitivity to noise. In acute
organic states noises may seem to come from an extreme distance and
if the examiner ^es care to apeak slowly, loudly, and distinctly, the
patient can accept reassurance. The delirious patient is less inHuenced
by incoming sensations, but more influenced by free rising fantasy than
the normal. Some anxious, preoccupied depressives experience all
sound as if it were coming from a long distance away and have great
difficulty in concentrating on what is being said. This experience can
be regarded as the auditory equivalent of micropsia.

e. Dutortims of Bodily Sensotion.-^Ezdi individual has an un>
consdous model of his body, which serves as a standard against which
the posture, movements, and other motor and sensory functions can be
assessed. This is the body image or schema. Lesions of the parietal
lobe may produce disorder of the body schema for the opposite half of
the body. The patient may say that the limbs on the side affected feel
as if they are not there, or he may actually deny that they are his own
limbs, saying that they belong to the person in the next bed. Very
rarely the patient has the experience of reduplication, i.e., that he has
two arms or legs on the same side of the body. Disorders of the body
schema due to lesions in the minor hemisphere are usually produced by
damage to the cortex and subcortical white matter of the supramarginal
and angular gyri. In the major hemisphere lesions of the angular gyrus
and the adjacent occipital lobe produce Gerstmann’s syndrome, con-
sisting of finger agnosia, right-left disorientation, agraphia, and
alcalculia (tee p. 60).

A hallucination which U best dealt with here is the ‘ plumtom limb
In fact, any part of the body if removed can leave behind a phantom.
The patient experiences the limb as if it were still present, but usually
it shrinks with time. Sometimes it is excessively painful. Strange
bodily sensations which appear to be disorders of the body schema
occur in schizophrenics and some l^terics. Thus some schizophrenics
complain of alterations in the size of parts of their bodies.

42

AN OUTLINE OPTSTCIIIATRY

THOUGirr DISORDER

General Observadons. — The urord ‘tfiinking’ is used rather
loosely in everyday English. Thus it may be used with the meanings of
remembering, believing, and attending carefully. If we exclude these
three meanings there arc another three which are legitimate uses of the
word ‘think’. These are: —

1. Undirected fantasy thinidng; audsde or dcreistic thinking.

2. Imaginadve thinking, in which the thought is dependent on the
environment to some degree and the ideas do not go beyond the possible
and the radonal.

3. Rational thinking, or reasoning in which the material is organized
in a rational way and an attempt is made to solve the problem faring
the individual. This can be called ‘conceptual thinking'.

Autistic Thinking. — Some individuals indulge in excessive fantasy
thinking. This may be a reasonable adjustment to an intolerable
shuadon. In the past it has been suggested that excessive fantasy
thinking might lead to schizophrenia, in which the fantasy apparendy
becomes real in the form of delusions and hallurinadons. This is
understanding too much. Excessive autisdc thinking occurs in schizo>
phrenia and Blculer suggested that this was due to the failure of logical
thinking allowing the fantasy to go on unchecked by rational
considerations.

Classification of Thought Disorder. — For purposes of descripdon
thought disorder can be considered as disorders of the stream of thought,
the po^ession of thought, the content of thought, and the form of
thought. No attempt will be made to separate thought and speech
disorders of the major funcdonal psychoses except in so far as the
speech act is obviously disorde^. Aphasic disorders will be
considered separately.

Disorders of the Stream of Thought. —

1. Inhibition of Thought . — The progress is slowed down so that
thought proceeds slowly and wth difficulty. This occurs in depression.

2. Pressure of Thought . — The patient feels compelled to think and his
thoughts run away with him. Some anxious depressed patients cannot
stop thinking about morbid topics and cannot concentrate on anything
else.

3. Flight of Ideas . — ^Thought is not determined by any overall
directing tendency, but ideas follow each other in quick succession, the
train of thought being determined by chance associations and clang
asoriations. This occurs in mania, but is sometimes seen in exrited
schizophrenics and in organic states, especially those due to hypo-
thalamic lesions.

GENERAL SYMPTOMATOLOGY 43

4. Thought Bloching . — ^The train of thought suddenly stops and a
new one, totally unconnected wth it, takes over. This is ch^ctenstic
of schizophrenia, but some exhausted and anxious patients may show a
rather jerky train of thought.

5. Incoherence . — Here one thought foUmYS another without any logical
connexion. This occurs in schizophrenia, delirium, and severe mania.

6. Circumstantiality . — Thought proceeds slowly with many unneces-
sary and trivial details, but the point of the discussion is finally reached.
This occurs in epileptics, the feebleminded, and in some obsessional
personalities; it is normal in some cultures.

7. Prolixity {Weitschrceifigheil ). — ^The patient is unable to keep
accessory thoughts out of the main stream of thought, but although the
goal of thought may be lost for the moment, the patient finds it again
and finaUy_ reaches it. The prolix patient embellishes his thlitking with
arabesques, while the circumstantial patient gives many wearisome
details, but never loses the goal of thought. Prolixity is the transitional^
stage between normal thinking and flight of ideas. It occurs in hypo-
mania and in hyperthymic personalities.

8. Perseveration . — ^Thia can also be considered to be a speech disorder.
The same thought which was initially relevant to the discussion is
repeated several times. Sometimes the exact words do not recur, but
the patient is unable to break away from the theme, which is repeated
in many different variations. This ts perseveration of theme and could
be regarded as a disorder of content. Both varieties of perseveradon
occur commonly In organic states, but are also found in schizophrenia.

Disorders of the Possession of Thought. — Normally we
experience our thoughts as belonging to us, or there is a quality of
‘my-ness’ of our thoughts. Apart from this we feel in control of our
thinking'. Both the control and the possession of thought can be
disturbed by mental illness. Thus the patient may be compelled to
think his osen thoughts against his will or he may experience his thoughts
as alienated from himself in some way.

I. Obsessions . — ^These are contents of consciousness which cannot be
got rid of, although when they occur they are judged as being senseless
or at least as dominating and persisting without cause.

The basic feature is that the obsession is experienced as occurring
against the patient’s will, but it is the patient’s own thought. If the
obsession leads to an act, then it is called a c ompulsi on.

The obsessional thought may occur alone in the form of ruminations,
or it may be part and parcel of the obsessional act, or the obsessional
thought may be followed by a compuluve act which is only indirectly
assodated with the preceding thought. Obsessive compulsive pheno-
mena can be classified into: (<2} Obsesrional ideas or mental images;

AN OUTLINB OF PSYCHIATRY

44

(6) Obsessional impulses; (c) Obsesuonal fears or phobias {see p. S3);
(d) Obsessional ruminations.

Obsessions may occur in obsessional neurosis, depression, schizo-
phrenia, and organic states.

2. Alimation of Tfsought , — ^This takes three forms: —

a. Thought tvithdrawal, or the experience that thoughts are taken
away from the mind.

b. Thought insertion, in which a thought is experienced as being
inserted into the patient’s mind.

c. Thought broadcasting, in •which the subject has the experience that
everyone else is participating in his thinldng.

Ail these experiences of thought alienation are characteristically
sch izoph renic.

Disorders of the Content of Thought. —

:. Definitions . —

A delusion'. A false unshakeable belief which is out of keeping with
the person’s educational and cultural background.

An over-valued idea: An idea that because of its feeling tone takes
precedence over all other ideas. It may be true or false. If it is odd or
persecutory in content it may not be easy to distinguish it from a
delusion.

2. Primary and Seeondary Delusions . — A primary delusion is one
that cannot be understood as arising from some other psychological
phenomenon, while a secondary delusion can be understood as arising
from some other psychological event, such as a depressive mood, a
suspicious attitude, and so on. Primary delusions consist of new
meanings or significations ariring in connexion with some psycho-
logical event. These experiences have been called ‘primary delusional
experiences’, or ‘experiences of significance'. Since some ne^T
meaning is becoming manifest Conrad called this phenomenon
‘apophany’.

3. Primary Delusional Experiences {Apophany ). — These occur in tlie
early stages of schizophrenia,’ but similar phenomena occur in some cases
of epilepsy. The new meaning may emerge in connexion with many
different psychological events. The older German psychiatrists isolated
a large number of such delusional experiences, but it is possible to
reduce them to three important ones: —

a. Delusional {apophanous) mood: This is a strange, uncanny feeling
state, in which the subject feels that there is ‘something going on’
around him, which concerns him ia some way, but he does not know
what it is. A sudden delusional idea or a delusional pereepdon may
appear and then the patient has a primly delusion and the mood dies
away. It may also cease mthout ai^ delusion emerging.

GENERAL STMPTOMATOLOGT 45

b. Delusional {apophanous) p>erception: A perception acquires an
abnormal significance, usually in the dire^on of self-reference, and this
abnormal meaning cannot be understood as arising from a mood state
or an attitude. It should be noted that in delusional mood the emerging
delusion cannot be understood as a natural sequence of the mood.

c. Sudden delusional idea {autochthonous delusion): A delusion
suddenly arises fully formed in the subject's conscious mind.

4. The Diagnostic Import of Apophany. — Delusional mood cannot
always be differentiated from states of anxiety and perplexity which may
occur in affective disorders and acute organic states or may be expected
among some religious sects.

Sudden delusional ideas can occur in abnormal personalities and in
manic-depressives. Delusional perception is diagnostic of schizophrenia,
as long as coarse brain "disease can be excluded.

5. Secondary Delusions in Depression. — Schneider has pointed out that
delusions in depression can be considered as morbid exaggerations of the
basic anxiedea which all human beings have to some degree. There
are four basic worries: (i) Anxiety about health; (2) Anxiety about one’s
moral worth; (3) Anxiety about one’s financial status; (4) Anxiety about
one’s relations tvith others.

Morbid exaggerations of the basic anxieties will understandably
produce delusions of bodily ill-health, guilt, poverty, and persecution.

is.^ypes of Delusion, according to Content . —

aTParanmd delusions: The word ‘paranoid’ strictly means that thereU
is a disturbance in the relation of the subject to the world, so that both >
delusions of grandeur and persecution are paranoid. However, when
the word is used without qualiScation by English-speaking psychiatrists
it usually means ‘ persecutory’. The delusional ideas found in this group
are as follows: —

Ideas of self-reference: The patient believes that people look at him,
talk about him, and that his surroundings have a special signihcance for
him. This may range from a vague feeling that this Is so, which the
patient recognizes as ridiculous, to a firm delusion. It occurs in
depressive states, schizophrenia, or^nic states, and in some abnormal
personalities.

Persecutory delusions: 'The subject believes that he is being persecuted
by individuals, orgamzations, or rarial groups, such as doctors.
Communists^ Je^’s.. and Freemasons. These delusions are common in
schizophrenia, but occur also in some depressions, organic states, and
in abnormal personalities.

Grandiose delusions: The patient believes that he is some important
person such as Napoleon, Jesus, or ewn God Almighty, or that he is
connected with important people, such as the Royal Family. This

46 AN OUTLINE OP PSYCItJATRT

o«ufs in schizophrenia, rarely m mania, and classically in G.P.r.;
although it Is more common in this organic psychosis than in others,
most cases of G.P.I. do not have grandiose delusions.

A. Hypochondriacal deltuiomt TTie patient bcIiCT’cs that he has cancer,
tuberculosis, syphilis, or some other dreadful disease. Very often
hypochondriac^ delusions and over-valued ideas are mistakenly
referred to as phobias, such as cancetophobia, and so on.

These delusions are very common in depressive illnesses, but can
occur in schizophrenia and in abnormal personalities.

c. Delusioru of guilt : The patient believes that he Is extremely wicked,
has committed a terrible sin. and deserves punishment In extreme
cases he believes that be Is eternally dunned and will be punished for
all eternity. The unforgivable sin U usually that of masturbation or
fornication, but occasionally It Is some sexual perversion or real crime.
Delusions of guilt mainly occur in depressive illnesses.

Paranoid ddusions may arise from delusions of guilt, since thesubject
believes that he deserves to be punished, and this attitude leads to a
misinterpretation of the environment tn the sense that the nell-reerited
punishment is being carried out

d. Dthuions of poverty: The patient is convinced that he is utterly
impoverished, despite documentary evidence to the contrary. This is
rare in present-day Britun, possibly due to the influence of the Welfare
State. It occurs mainly in depressives.

e. NthJlislie deliuiont: These occur chiefly in very severe depressions.
The patient believes that he is dead and e^’crythlng around him is dead
or has stopped working.

Disorders of the Form of Thought — InTormal thought disorder
there is an inability to think abstractly in the absence of coarse brain
disease, although there is eridence that the patient has had that ability
in the past Evidence that abstract thought was present in the past is
the occurrence of words out of keeping with the low le%’cl of intellectual
performance or information that there was a reasonable intelligence in
the past. Formal thought disorder is characteristic of schizophrenia,
where it occurs as: (t) Negative formal thought disorder; (2) Positive
formal thought disorder.

1. Negative Formal Thought Disorder . — ^The patient shows an
inability to ihirtk abstractly, but does not produce any false concepts.
This variety of the disorder cannot always be dbtinguished from that
due to defertive motivation, catatonic disorders of attitude, or
inattention.

2. Positive Forma/ Thought Disorder . — This is the liBoftfer whrti is
^ usually meant by such terms as ’sduzophrenic thought disorder’ and

‘thought disorder’ in the Englbh literature. It has been described by

CENERAt SYMPTOMATOLOGY 47

many different workers, each with Ws own terminology for the same
phenomena. Cameron’s description and terminology are the most
convenient, and are described u^cr the following four headings; —

a. Asyndetic thinking This means that there is a lack of genuine
causal links in thinking. The patient uses clusters of more or less related
sequences in place of well-knit sequences. There is a lack of ability to
eliminate unnecessary material and focus on the task in hand.

b. Metonyms and personalidioms". The patient uses metonyms, which
are imprecise approximations in whidt some substitute phrase or term
b used instead of a more exact one. The patient uses hb own private
mode of speech which b full of personal idioms,

e. Interpenetration of themes'. The patient’s speech contains elements
which belong to the current task interspersed in a stream of
preoccupation which he cannot stop.

d. Orerinehuion'. Tliere is an inability to maintain the boundaries of
the problem and to restrict operations trithin their limits. Thb means
that the subject carmot narrow down the operations and bring into
action the relevant organbed attitudes and speciiic responses. The
schizophrenic U therefore able to generalize and to shift from one
hypothesb to another, but hb generalizations are too involved, too
indusive, and much too entangled with private fantasy.

Neologisms.— These are new words invented by the patient or
standard words to which the patient has given a new meaning. Thb can
be due to gross positive formal thought disorder. In other cases the
new word has been invented by the patient to designate an experience
which is outside all normal ex(>erience. Sometimes the new word b
really a catatonic symptom, of the nature of a stereotypy or mannerism.

Disorders of Thinking mainly due to Disordered Attitudes. —

1. Self-reference of Thinking. — Some patients, usually chronic
schizophrenics, are unable to deal with any problem without referring
it to themselves.

2. Talking Past the Pointtyorbeirederi). — Here the patient deliberately
gives the wrong answer and this is shown by the content of the wrong
answer, which b a falsification of the correct one. This typically occurs
in hysterical pseudo-dementia, but it also occurs in some young acute
schizophrenics, who have a silly facetious attitude due to their illness.
It b also seen in a fetv chronic catatonics.

DISORDERS OF MEMORY
The Essential Steps in Remembering. —

I. The material has to be peredved and understood. This usually
takes pbee within the framework of schematbed past experience.

48 AN OUTLINE OF PSYCHIATRY

2. The new material must be stored in a short-term store which
allows the material to be evaluated. If the material is relevant. It is
fitted into the organized body of Imowledge ; if not, it disappears after
a minute or so.

3. If it is fitted into the organized body of knott-ledge then some sort
of permanent trace is formed, possibly due to gro^vth at synaptic
junctions.

4. The trace lasts until recall, but undergoes changes because of the
effects of intcPi'ening activi^.

5. A netv situation requiring the utilization of the information stored
in the trace has to be recognized.

6. The required information has to be isolated from the rest of the
stored materials. This is the final stage in experiments on memory, but
in everyday life we make use of the information we have recalled by
using it in dealing with the current task.

It is obvious that memory is only one aspect of Intelligent be-
haviour, so that isolated defects of memory, without any diminution
in intelligence, are not likely to occur in coarse brain disease.

Total Amnesia. —

1. Psychogenic Amnesia. — ^Thc memory for a period of lime and
often also for personal identity b more or less consciously repressed.
Sometimes severe amde^ produced by some personal problem causes
a restricUon of the field of consciousness and inattention to the entdron*
ment. This suggests the idea of amnesia, which is then unconsciously
exaggerated. In many cases amnesia of this kind seems to be maJinger-
ing rather than hysteria. WTien In doubt wait fot the police to arrive
with a complaint of criminal behaviour.

2. Organic Amnesia. — Head injury, epileptic fits, and acute organic
states can produce total amnesia. Retrograde amnesia extends back-
wards in time from a given point. Anterograde amnesia begins at a
given point and extends over a period, during which the subject
appears to be fully consdous. Both these types of organic amnesia are
not as complete as appears at first sight, because with hypnosis or
intravenous sodium amylobarbitone a large part of the forgotten
material can be recovered.

Specific Memory Defects. —

1. Minute Memory. — In some acute and chronic organic states new
material cannot be integrated into the schematized past experience, so
that it exists for a period of 50-60 scronds and then disappears. Thb is
minute memory.

2. Failure 0/ Registration. — In the past it was customary to say that
memory consisted of registration, leteation, and evocation, which was

subdivided into recall and recognition.

GENERAL. STMPTOMATOLOGT

49

It ^vas claimed that a failure of registration ^vas the outstanding
feature of the amnestic or Korsakoff syndrome. This -was sometimes
expressed as a ‘ loss of impresMbility* and from time to time it has been
claimed that permanent complete loss of impressibility has been
produced by acute coarse brain disease. In some patients with severe
acute and subacute recoverable brain damage and in others with severe
chronic progressive brain disease ‘minute memory’ occurs and the
patient is unable to integrate new material into his schematized past
experience, so that any new material is main tained in the short-term
store for 50-60 seconds, after which it is replaced by some incoming
stimulus.

3. Failure of Recall, — ^This occurs in anxiety, fatigue, generalized
coarse brain disease, and in aphasia due to focal brain lesions.

Distortions of Recall. False Memories. —

Paramnesia, — ^This is a morbid distortion of memory produced by an
attitude or emotional state. It occurs in normals, paranoid personalities,
depressives, and sometimes in manlcs.

Retrospective Falsification. — ^The past is falsified in keeping with the
person’s present attitudes and moods. Some depressed patients may
falsify their past and assert that they have ^ways been useless,
incompetent people. This may lead the unwary examiner to believe
that they are inadequate personalities. Some paranoid patients claim
that their delusions have existed for years despite evidence frona friends
and relations that the delusion is of fairly recent origin.

Fahificaiions of Afemory.— Isolated memories are produced with
unshakeable conviction, but are completely false, _ _ .

Confabulation. — Detailed descriptions arc given of past events which
are false. Usually they are plastic and can be modified to suit circum-
stances. They occur in the amnestic syndrome and if they are not
produced spontaneously the patient can usually be provoked into
confabulating. Confabulations dsooccurinsome chronic schizophrenics
and in patholo^cal liars.

Delusional Memories. — ^These may be apophanous in the acute phase
of schizophrenia since a new meaning arises in association mth the
memory. In some cases the new rignificance is associated with a
memory image; for example, a patient remembers that there was a
crown on his fork when he was a boy and this means that he is of Royal
descent. In other cases the memory contains the delusion, as when the
patient remembers being told that he was of Royal descent.

Distortion of Reco^tlon. —

Dijii tu and D^d V/cu Experiences. — The subject has the impression
that he has seen or experienced the rituation before. This ocrars in
normals but may occur in attacks of temporal lobe epilepsy.

50 AN OUTLINE OT rsYCHJATRY

Delusional Mlsldcntincation. — Some acute and chronic achlzo*
plirenics misidcnlify all the people in their environment. In acute cases
this may be a variety of delusional perception, while in tlic chronic
cases it may be due to perceptions acquiring the sense of acquaintance,
usually only possessed by memory images. Other patients refuse to
admit that their friends and relations arc really these people and insist
that they are strangers.

DISORDERS OF CO.VSCfOUSN'HSS
Definitions. —

1. Cuniriouinwj. — 'I'hts is a state of awareness of one's self and
environment. It is usual to compare it to a stage on which im-sges
appear like actors; so that consciousness can i>c restricted or clouded or,
to continue Uie simile, the actor may be spotlighted, or the footlights
may be wxak.

2. Can/uaon . — This is a lowering of the level of awareness and is
indicated by disorders of attention, grasp, and orientation. Some
patients are puzzled and pcrplesrd, but are not confused, altliough a
lay penon might use thu term. 'The word ‘confusion* as a psjchiatric
technical fenn means a definite dnturbance of con«ciousnes5. It occurs
in aevere transient and' permanent brain dpfunction.

3. This is the ability to bring a percept or concept Into
the forefront of consciousness, or to focus on a content of conidouineM.
Tills may occur actively or passively, i.e., tlic subject can direct his
attention to some content of consciousness or his attention may be
attracted by some content witbout any active cfTort on his part.
Attention depends on the amount of fatigue and the emotional state.
Fatigue and anxiety may make active attention difficult os docs any
disorder of consciousness. On the other hand, passive attention maybe
affected in anxiety, in some excited schiropfircnica, in manics, and in
some organic states, so tliat there is undue distracubility. Some
hptcrical personalities and over-active children are also unduly
distractible.

4. Grasp or Compreltensian . — ^This is the afiiliiy to assess the current
situation and bekive correctly in relation to it. Naturally it is a function
of intelligence, but in confused patients it is often obvious that the
patient’s comprehension is not in keeping with hia sodal status, his
intelligence, as estimated from hb occupation and the words he uses
and occasional excellent perfonnanccs on intellectual tests,

5. Orientation . — It is customary to talk of orientation for place, time,
and person, i.e., the patient knows where he is, what the time is, and
who he is. Disorientation is usually present in acute organic states with
clouding of consciousness and in chronic organic states with memory

GENERAL SYMPTOMATOLOGY 51

disorders. It also occurs in hysterical fugues and rarely in acute
paranoid schizophrenia, when delusions and hallucinations may
produce a false orientation, although the patient usually knows the
correct one if he can be induced to give it.

Types of Disordered Consciousness. —

DTeam~Uke Clouding of Consciousness. — The level of avfareness is
lowered.' Memoiy images crowd^into consciousness wthout the patient
being able to select the appropriate ones. These images acquire the
same importance as percepts. ’‘Active and passive attention are both
decreased ^d the threshold for all stimuli is raised, Once_a^timulus
rises above the threshold, it can be incorporated in the incoherent
thoughts or even form the basis of an illusion.

Vis ual halludn atinns are a usual feature of this type of disorder,
which occurs in delirium due to infections, biocheml^ disorders, and
so on.

Stupefaction. — Ther e is a general depression of the level of conscious-
ness, togetl^r with a depression of all mental and motor activity.
Thinking it.difficult and thought is fragmented. Attention is difficult
to arouse and poorly maintained. In extreme cases the patient is
stuporose, but in milder cases, due lo subacute brain disease, the patient
may be mistaken for a dement

This disorder of consciousness is due to acute and subacute coarse
brain disease.

Restriction of Corucioumess. — ^The field o/_cqnsciot«n^_ss j_s_reMncted,
so that a small group of ideas, feelmgs, and drives dominates all thinking
and action, whilst all other possible contents of consciousness. Including
all opposing ideas and drives, are completely excluded from conscious-
ness. Usu^ly cpnsciousnessis.also^lightly clouded, but this may not
be obvious to uninformed bystanders. In this state patients may
wander for a day or so.

This disorder of consciousness occurs in twilight states due to brain
disease, particularly in epilepsy.

Fugues. — ^These are >vandering states with some degree of loss of
memory. Consciousness is disordered by brain disease or, what is
more common, by anxious preoccupation. Them is no sharp distinction
from twilight states. Fugues occur in acute coarse brain disease, in
hj’Steria, and in suiddal depressives.

Sleep Disorders. —

Hypersomnia. — This is an incre«e in the amount of sleeping. It
occurs in diseases of the hypothalamus, in hysteria, and in.psychopathic
personalities in trouble.

Harcolepsy. — ^The patient suddenly falls asleep. Attacks are often
provoked by emotion and it occurs in lesions of the hypothalamus.

52 AN OUTLINE OF PSyCiriATRr

Insomnia . — It is never easy to be sure if a complaint of insomnia is
true or hypochondriacal, due to neurosis or ^depression. Anxious
patients have difficulty in getting to sleep. Depressive patients with'
‘endogenous’ depression have difficulty in staying asleep^, which usually
consists of waking at 2 or 3 a.m. and hating diificulty in getting back to
sleep. Some of these patients may wake two or three hours before their
usual time and lie awake until it is time m rise. Some depressives have
broken sleep, waking and drowsing throughout the night. Anxious .
depressives have dlfliculty in getting to sleep and in staying asleep.

Some patients claim that they do not steep at all. Usually this is
either hypochondriacal or hysterical exaggeration.

IniersiontiJ SUtp Rhythm . — The subject sleeps through the day and is
awake and restless at night. This is produced by hypothalamic lesions.

Sleep Deprivation . — Deprivation of sleep for 36 hours or more can
produce hallucinations and paranoid attitudes. Such deprivation may
occur during prolonged first stage of labour, in anxious mothers with
restless infants, and so on.

DISORDERS OF EMOTION AND FEELING

Derinidons.—

t. Feeling and Emotion.-^U is usual to distinguish bettvecn feeling
and emotion. Arnold (1961) gives the following definitions; —

Feeling: ‘A positive or negative reaction to some experience.'

Emotion: ‘The felt tendency toward anjthing intuitively appraised as
good (beneficial), or away from anything intuitively appraised as bad
(harmful). This attraction or aversion >9 accompanied by a pattern of
physiological changes oigantzed toward approach or withdrawal. The
patterns differ for different emotions.'

2. Affect . — The term ‘affectivily’ includes the whole of the
lemotional side of life, but an ‘affect* is asudden accentuation of emotion
(of short duration and marked intensity, often reactive.

3. Mood . — This is an emotional state, usually of some duration, in
which the total experience of the subject is completely coloured by the
prevmling emotion.

Mood Changes, — Mood changes and affective swings in the mentally
ill are sometimes a normal response to an abnormal experience. Thus
many schiaophrenics become very frightened when they first hear voices.

Abnormal mood states can bedividedinto: (1) Elation ; (a) Depression ;
(3) Anxiety; (4) Irritability. It is often assumed that elation and
depression are necessarily qualitative exaggerations of the cheerfulness
and unhappiness which are a natural part of cr'eryday life, but the mood
changes in manic-depressive illnesses often seem to be qualitatively
different from normal.

GENERAL SYMPTOMATOLOGY 53

1. Elation, — T his is a state of matted cheerfulness assoc iated >vith
infec tious .gaiety. It occurs in mani a, but is occasionally seen in
sch izophr enia and in patients with lea ons a ffecting the hypgthal^us.

Euphoria is a stat e of mU d unwarranted cheerfulness. Th is is often
associated .with asense ofJaQdilyjrell-bcing called ‘eutonia’._

2. Depression. — ^Thjs. is a f eelin g_of_dejection which-colours ..all
thQught..and ^activity. There b a marked difference between reactive")
unhappiness, which is called 'depression* in everyday speech, and the \
unpleasant mood state which occurs in constitutional depressive >
illnesses. To distinguish between the different meanings of this word
ithe term 'autonomous dysthymia* will be used in brackets whenever
^he word ‘depression* is used in the second sense In this book.

Anxi e^ o ft en occurs in au tonomous dj'sthymia.

3. Anxiety. — ^This term is a translation of the German word Ang st
which means ‘a fear without an objec t or a dread*, since the word
Furcht meaning ‘fear’ must always have an object. Unfortunately,
the word ‘arudous* in everj'day speech is used for being worried about
something.

As a psychiatric term anxiety is ' an unpleasant affective state with the
expectation, but not t h e ce ftainty,_pf something happening’ (Lewis),
^ite often, how'ever, in psychoanalytic and psychodynamic discussions
the tvord 'anxiety* is used in the sense of fear. Thus the 'anxiety states’
which occurred In British soldiers during battle were states of excessive
fear, but in a democratic army men cannot be shot for cowardice.

Tension is an xiety wit h increased muscular tension of which the patient
b conscious. In Scotland many anxious patients describe themselves as
‘all tensed up*.

Panic occurs when sev'ere a nxiety or fea^lea^ to chat^ic motor
behaviour.

Phobia is an an xiety or fea r_ restricte d_to one situation, ©yect, or idea.
Phobias can be due to different causes: —

^ Conditioned or learned phobias'. The cMld Ieamsjo.be frightened pf a
najural event, such as thunder, or an animal, such as a mouse or frog,
cither because a parent or parent substitute is frightened by these
things, or because of some traumatic experience associated with such
events or animals.

^ Obsessional phobias {see p. 83) : The patient is frightened that something
might happen. He is compelled to think about it although he realizes
it is ridiculous or at least that it persists in his mind without cause.

4. Irritability. Ill-humoured Mood States. — Some patients have ill-
humoured states of mood, in w hich they are u nhap py, m iserab le, angry ,
resentful, and irritable. These states most commonly occur in epilepsy,
but can be seen in d epressi on (autonomous dysthymia), in abnormal
indiriduals, in para noid mania, and in rompensatioo neurosis!

54 AN OUTLINE or PSYCHIATRY

Abnormalities of Emotional Expressions. —

\Emotional Indifference . — Here the patient slio\\3 complete indifference
to one situation, or, to put it in another way, all emotion associated with
a given event is dissociated. Thus criminals after committing a violent
crime may discuss it nilh no croorion. This emotional indifference is
often seen in diildren and adolescents who, being unable to tolerate
the emotional complications of their interpersonal relationships, say
that they do not care and act as if they did not.

-.Belle indifference is a special variety of emotional indifference. Here
the patient shows no emotion, but a bland indifference to some severe
hysterical symptom.

Emotional Lability and Emotional Incontinence . — Many normal people
are easily moved to tears and in some cultures weeping is acceptable in
both sexes. In Britain men are expected not to weep, so that tears in a
British man are usually the sign of a serious upset. Many depressives
(autonomous dysthymics) are easily moved to teats.

Emotional incontinence occurs when the subject bursts into tears or
laughter for little or no reason. Usually it is weeping and this occurs
in coarse brain disease, especially in arteriosclerotic dementia. A few
patients ufth brain disease hai'e attacks of forced laughing or crying.

Inadeijuate Exprettion of Affect. — ^Thc_patient showa in^ffident or
inappropriate affect in relation to the situation. This*' occurs 'in
set^ophrenia and when well marked it is diagnostic. It should be
remembered that some armous patients smile foolishly when talking
about serious topics, as do deaf people when they have not heard all
that has been said to them. Some middle-aged depressives (autonomous
dysthymics) smile when talking about their deficiencies and make wvy
jokes about themselves.

Depersonalization. — ^The subject has the feeling that he has no
feeling. He finds that the normal swing of emotion when he sees ius
friends and loved ones is absent and if depressed be may reproach
himself bitterly for this apparent callousness. Tlus is often assodated
with derealization in which the environment is changed in a strange
unreal way. It looks flat or ‘made of cardboard*.

Depersonalization may occur in d^re^sion, schimphrenia, hysteria,
and normal subjects.

Perplexity. — ^Thc parient is puzzled and bewildered. This may be
due to anxiety produced by situational difficulties or by depression
(autonomous di^thymia). In the early stages of schizophrenia the
apophanous experiences may produce bewilderment.

Ambivalence. — ^THs is the prcsencc_in_ihe,mind.o£-the_oppositc
attitu des towards a person, idea, or action. All of us have contradictory
attitudes towards certain ideas, but one of the two attitudes is

GENERAL SYMPTOMATOLOGY 55

unconscious while the other is conscious. In schiMpIwenia these twx>
opposed emotional attitudes and ideas may be more or less present at
the same time or alternate rapidly in the conscious mind.

Ambivalence towards an act, or ambitendency, is a disorder of motor
behaviour in which the subject stops and starts a voluntary act several
times before completing the act, or failing to do so. This is especially
well seen in some catatonic patients who, when the doctor offers to shake
hands with them, move the right hand fonvard towTirds his, but stop
and start again several times before shaking hands or abandoning the
attempt.

DISORDERS OF INTELUGENCE

Definition of Intelligence. — ^Wechsler defines intelligence as:
‘The aggregate or global capaci^ of .the individualto act_purpose-
(uUy, lf>_think rationalIy,_and jo deal effectively with his environ-
ment. '

Dementia. — This is a permanent loss of intelHg^ce due t o co arse
brain disease. The term should not be used for reversible intellectual
impairment due to acute coarse brain disease, or for personality
deterioration in schizophrenia.

Deterioration.— Schizophrenia tvas originally called ‘dementia
praecox’ and chronic patients were srid to be ‘demented’. Such
patjents have no coarse brain disease.and are therefore ‘deteriorated’.

Amentia.— This is used in English to mean_a lack ofjntelligence
obvious at an early age. In German it is used to designate subacute
delirious states.

MOTOR BEHAVIOUR

Subjective Experience of Behaviour. — Obsessions and compul-
sions can be regarded as disorders of behaviour of this kind, since the
normally subjective experience of the progress of thought and action is
disturbed.

The most outstanding abnormalities of this kind are thejeelings of
passivity, when the patient has the experience that his thoughts, feelings,
and actions are not his own and that he is made to do these things by
outside influences. This may be attributed to rays, radio waves,
atomic rays, television, witchcr^t, and so on. Theselmadelexperiences
aic.diagnosticjoLschizophrenia.

Classification of Objective Motor Disorders in Mental
Illness. — Motor disorders can be classified into: —

I. Disorders of Adaptive Movements . — ^These may be disorders of: —
\a. Expressive movements.

\fr.- Reactive movements.

er Goal-directed movements.

56 AN OUTLINE OF PSTCHIATRY

2. Non-adaptive Mocettienls , —

a. Spontaneous morements.

b. ' Induced movements.

3. Difordert 0/ Posture . —

a. Distorted normal postures. Manneristic postures.*^

b. Abnormal postures. Stcreoq-'ped postures.'^

4. Abnormal Behaviour Patterns . —

a. Non-goal-directcd patterns of behaviour.

'b,- Goal-directed abnormal patterns of behaviour.

Disorders of Adaptive Movements. —

Expressive Moiemenis. — In manic-depressive disease there is an
excess of expressive rao^•ement in maiua and a lack of it in depression.
The manic shows a nide range of expressive movements and tends to
use his hands and upper trunk to express hb feelings, so that large
expansive movements are made. In contrast the depressit'e shows
poverty of facial expression and what there is is sad and protmked by
morbid topics. Some depressives smile and make wry jokes about
themselves — a sort of ‘gallmvs humour’. These patients, rather like
actors, smile with their lips but not with their eyes. Depressed
retarded patients often have an angulation of the inner end of the fold
of skin in the upper eyelid (Veraguth’s sign).

In schizophrenia expressive movements may be severely affected.
Thus in catatonia the face is usually flat and expressionless, or at least
facial movement is stiff, although the eyes may show some liveliness.
Other cautonics have excessive grimacing and facial contortions.
Sometimes they show Schnaiakrampf in which the nose is wrinkled
and the lips are excessively pouted, giving the appearance of an
animal’s snout

In post-encephalidcs the face is usually flat and expressionless and
very greasy-looking — ‘the omtracnt face’.

Reactive Movements. — ^Thesc arc the immediate adjustments to
stimuli which are carried out automatically. In catatonia and motility
psychoses these movements may be lost before voluntary movements are
affected. This gives a general stiffness of movements which is difficult
to describe.

In anxiety reactive movements tend to be rapid and excessive. In
retarded depression they are diminished.

Goal-directed Movements. — ^Tbese ate usually carried out effortlessly
and smoothly. In depression movements may be slow and tired, but in
amuety they are quick and irenwlous. In catatonia they am often
awkward and lacking in grace. Voluntary movements reflect the
personality and mood state, so that the movements always show some
individuality. If this individuality b excessive, then we can speak of a

GENERAL SYMPTOMATOLOGY 57

maimertsm which is an unusual variation in the execution of a goal-
directed movement or normal posture. Mannerisms occur in abnormal
personalities and in some schixophrenics.

Non-adaptive Movements. —

Spontaneous Movements . — The commonest spontaneous movement
is tremor, which occurs in anxiety. The various organic tremors will
not be discussed here, but it must be pointed out that organic tremors
can vary in severity and are made worse by anxiety so that such ^’ariations
are not indicative of the psychogenic origin of a tremor.

Tics are short, jerking movements of the face, neck, and upper trunk.
They are often provoked by psychological dliBculties, but they cannot
be regarded as hysterical conversion symptoms.

Spasmodicjtorticollis consists of spasfns of Uvisting of the head. This
is made worse by psychological stress, but is determined by an abnor-
mality in the nervous system.

Choreiform movements are short, jerkiog movements affecting the
whole body. In Sydenham’s chorea they are fine movements and affect
the periphery more than the trunk. In Huntington’s chorea they are
coarser and affect the face, upper trunk, and arms. Grunting and
snorting noises also occur in chorea.

Stgisfitypy consists in the repeated performance of a non-goal-
directed action in a uniform way. Sometimes it is possible to discern
the remnants of some purposive movement This leads psychoanalysts
to interpret these movements as representing some symbolic act.
Stereotypies occur in catatonia and in oi^nlc states.

Some catatonics show par^n esia, in which there is a continuous
irregular activity of the whole musculature, including the face, and
resembling the movements of Sydenham's chorea.

Some catatonics have continuous handling and intertwining move-
men ts. They knead and fiddle with the cloth oTtheir trousers or skirts
and handle all objects >vithin reach.

Abnormally Induced Movements . — ^These can be regarded as the
result of undue compliance on the part of the patient: —

xO^Automatie obedience’. The patient carries out all instructions.
This is sometimes called ‘command automatism’, but this term has
also been used for the syndromes of waxy flexibility, echolalia, and
echopraxia.

‘jK'Echopraxia: The subject imitates all the actions of the examiner.
Echolalia is present when he repeats what is said to him. Echolalia and
echopraxia occur in schizophrenia and dementia.

e.^PeTseveTation: This is the repeated useless repetition of a goal-
directed act. This may occur in speaking, so that the patient
repeats his reply to a question se\'eral times. Perseveration is

S8 AN OUTLINE OF FSTCltlATRY

most commonly seen in the demcntlis, but can occur In catatonia.
Palilalia and logoclonla arc special varieties of perseveration affecting
speech.

d. Forced grasping and greying: In forced grasping the subject tales
the examiner's hand every time it is offered despile instruction to the
contrary. This is different from the grasp reflex, in which the patient
grasps everj'thing which touches his palm. The grasp reflex occurs
bilaterally in tuticspread cortical lesions, but may occur unllacerally in
tumours of the frontal lobe. A few patients will grope after tlic
examiner's finger if he repeatedly touches the palm of the subject’s
land while slowly moving the finger away. This is the soiled
‘nugnet reaction’. Forced grasping may occur in catatonia and in
coarse brain disease.

e. Milgehen: This usually occurs in association svith forced grasping
in some catatonics, but can occur In frontal lobe lesions. The subject's
body can be moved in any direction by light pressure, despite instruc-
tions to the contrarj*. Once the pressure stops the body slowly returns
to the resting position.

/. Co-operation or Mitmacheni The patient allotvs his body to be
moved without the slightest resistance and when the doctor stops the
body slowly reverts to its rest position.

g. Oppontion'. The patient rerists all passive movements to the
same degree as the force being applied by the examiner. If move-
ments are carried out very gently then the patient often does not resist
them, but as soon as abrupt forceful movements arc attempted opposi-
tion occurs.

Disorders of Posture. — Manneristic postures are odd, stilted
postures which are not rigidly maintained, while stereotyped postures
are abnormal postures which arc rigidly maintained. This distinction
is not always easy to male. One stereotyped posture which is seen in
both catatonics and dements is the * psychological pillmv*. The patient
lies for hours with hia bead nvo or three inches off the pillow.

Flexibilitas ccrca or waxy flexibility occurs m patients with catatonia
and in those with lesions affecting the brain-stem. The patient allows
his body to be placed in awkward positions and there is a feeling of
plastic resistance as the examiner mox'es the body. The position is
maintained for more than one iranutc. Preser^-ation of posture or
catalepsy occurs when the patient maintains a position in which the
examiner puts him, hut there is no sense of plastic resistance.

Abnormal Behaviour Patterns. —

I. Xon-goal-directed Sehariour, Stupor and Excitements.—

a. Stupor: This can ocair tn depression, catatonia, hj-steria, and
coarse brain disease. The patient lies or sits motionless and docs not

GENERAL SYMPTOMATOLOGY 59

reply to questions, or if he does he gives muttered monosyllabic
replies. In depression (autonomous dysthymia) psychomotor retarda-
tion occurs in which all thought and motor activity are slowed down.
\Vhen this becomes extreme, stupor occurs, but usually the face looks
depressed and is not entirely expressionless as in catatonic stupor and
there is some emotional response to afTect-laden questions. Inointinence
of urine and faeces frequently occurs in catatonic and organic stupor,
but hardly ever in depressive or hysterical stupor. In organic and
catatoruc stupor disorders of posture such as flexibilitas cerea may be
present. In catatonia the stupor may pass into an excitement or be
briefly interrupted by an impulsive act.

Some catatonics show very little spontaneous activity but will eat
when food is put before them and micturate and defaecate when placed
on the toilet. As they can, therefore, unlike the stuporose patient, be
pushed into activity, this state can be called ‘akinesia’,

b. Excitements : These occur inmania, ioseverely agitated deprcssives,
in catatonia, in paranoid schizophrenia, in delirium, in psychogenic
reactions in mental defectives and unsophisticated individuals, in
psychopathic personalities, in hysterical females, in epilepsy (epileptic
furore), and in other organic states. The gay, infectious mood in the
absence of hallucinations usually makes the diagnosis of manic excite-
ment fairly easy. The other conditions are not easy to differentiate from
one another.

e. Negativism'. This is an active striving against all external attempts
to influence behaviour. The more the examiner insists on examining
the patient the greater the resistance, so that excitement may occur.

2. Goal-directed Behaviour. — ^This covers the whole of mental illness,
so that only the following outstanding behavioural patterns sometimes
seen in severe mental illness can be discussed: —

a. Silly behaviour: Some hebephrenics smile foolishly and behave in
a childish, silly way.

b. Unpleasant tricks'. Some abnormal personalities and manics get
much enjoyment out of practical jokes. Some hebephrenics play
unpleasant pranks on their fellow patients.

c. Brutality'. Such behariour Is common in aggressive psychopaths,
but some emotionally devastated chronic schizophrenics behave in a
brutal, inconsiderate way.

d. Manneristic behaviour: Some abnormal personalities carry out
complicated patterns of behaviour in a manneristic way. Thb is also
seen in some chronic schizophrenics.

e. Immoral behaviour: This per se is no indication of mental illness,
but immoral behaviour may be released by coarse brain disease,
schizophrenia, or mania. Thus in so-called 'simple schizophrenia’ one
of the outstanding features is the ethical and moral deterioration.

6o AN OUTLINE OF PSYCHIATRY

/. Murder'. Despite the popular press and novelists this is not a
common feature of mental illnesa (see p. 233). In Britain most murders
are committed by distressed, unhapp)* people, and not by the insane.

SPEECH AND WRITING

General Disorders of Speech. — Some schizophrenics show
abnormal attitudes totvards the questioner. They may always turn to
the speaker or turn away when spoken to. The former (adient) patients
may always speak when spoken to or merely stare fixedly at the
examiner. If they speak it may be drivel, i.e., it is grammatic^y well-
formed, but the content is nonsense; or there may be verbigerations
consisting of the repetition of the same senseless syllables.

Mutism occurs in stuporose states due to all causes, but is also seen
in some catatonlcs in whom it appears to be a mannerism. Such patients
may write, although they refuse to speak. Mutism can occur as an
isolated symptom in hysteria, but is not as common as hysterical
aphonia.

Perseveration (see p. 43) occurs in schizophrenia and coarse bran
disease. In some dementias, such as Alzhelmers’ disease, palilalia occurs.
This is the repetition of a phrase with increasing speed. Logoclonia, the
rapid repetition of the last syllable of what has just been said, e.g., ' I
am all right-ite-itc>ite-ite*ite’, also occurs in the same conditions.

Writing In the Neuroses and Functional Psychoses.-*
Schizophrenic patients show mannerisms and stereotypies In their
tvriting. Letters may be distorted or embellished and the lines of script
may be arranged in a design. Some schizophrenics show much more
thought disorder in ^vritten than in spoken productions, but the reverse
also applies.

NOTE ON NEUROLOGICAL DISORDERS OF SPEECH
AND ALLIED TOPICS

Since some schizophrenics show features like aphasic disorders and
some dements have aphasia, a short acwount of aphasia and related
subjects will now be given.

Aphasia. — The incoming sensations are recognized as percepts in
the cortical area in which th^ temunate, but these areas must be
connected to the other sensory areas and to a central co-ordinating area
on the left side in the right-handed, comprising the posterior part of the
first temporal convolution and the adjacent parts of the parietal and
oedpita! hbes. In this area preUmlaar}' seherriata for words are
elaborated and impulses pass forward to the posterior part of the first
frontal conTOlution to evoke the motor schemata for speech, giving rise
to impulses which pass the lower end of the precentral convolution.

GENERAL SYMPTOMATOLOCT 6l

which gives rise to impulses which pass to the speech musculature via
the appropriate motor nuclei. Aphasias can therefore be classified
according to whether the disorder is predominantly receptive,
interrae^ate, or expressive.

1. Receptive Aphasia . —

a. Pure icord deafness". Words are heard, but not understood. The
lesion is in the first temporal convolution near the first transverse
temporal gyrus,

b. Agnosic alexia". Words are seen but not recognized, although the
patient can write spontaneously and to dictation. The lesion is one
which interrupts the coimexions between the visual cortex on both sides
and the left angular gyrus in the right-handed.

c. Visual asymholia {cortical visual aphasia): The patient has
difficulty in reading and writing. The lesion is in the left angular gyrus
in the right-handed.

2. Intermediate Aphasia . —

a. Nominal aphasia {amnestic aphasia): The names of objects cannot
be evoked. The lesion is in the left temporoparietal region in the
right-handed.

b. Central aphasia: There is a defective comprehension of written
and spoken words and also of grammatical relationships, together with
grammatical and syntactical errors and the misuse of words in
spontaneous speech. The lesion is in the posterior part of the left
temporal com*olution.

3. Expressive Aphasia . —

a. Verbal or cortical motor aphasia: There is difficulty in the use of
words, so that in severe cases speech is almost entirely absent. Words
are often distorted and the patient knows what he wants to say, but
cannot find the right words. The lesion is in the posterior nvo-thirds of
the first frontal convolution.

b. Pure ssard dumbness: All spoken speech is lost, but inner speech
and writing are preserved. This disorder occurs in lesions affecting
different parts of the anterior portions of the brain.

Apraxia, — This is an inability to perform or carry out a volitional
action in the absence of any motor or sensory loss or disorder of
co-ordination.

Limb-kinetic Apraxia. — ^There is an inability to appreciate the
constituent elements of a movemenL Some neurologists claim that this
is due to a slight damage to the pyramidal tract.

Ideomotor Apraxia . — ^The subject can imagine the act which he wants
to perform, but he is unable to do it. A lesion in the dominant parietal
lobe produces this disorder bilaterally, but a lesion in the corpus
callosum may cause this apraxia on the opposite non-dominant side.

62 AN OUTLINE OP PSYCIirATRY

Ideational Apraxia . — ^The padent U unable to carry out a complex
series of acts, although he may be able to imitate simple tnovements.
The lesion is in the dominant parietal lobe.

Constructional Apraxia . — ^Individual movements can be carried out
accurately but actions cannot be properly ordered in space. This is due
to a failure in the integration of kinaesthetic and visual elements in
spatial perception.

Apraxia for Dressing , — ^The patient is not able to relate his body to
his clothes, so that this is partly due to apraxia and partly to a disorder
of the body image. It occurs in lesions of the parieto-occipital region
in the non-dominant hemisphere.

The Agnosias. — In agnosia the subject experiences the sensations
in the given sense modality, but cannot recognize objects in this
modality, tvhile he is able to do so in other modalities. Agnosias are due
to an interruption of the connexions between the specific cortical area
and the rest of the brain. IVhen these disorders occur in isolation they
can be mistaken for hysterical complaints. Thus a patient with
visual object agnosia said he tvas blind and this was interpreted by the
examlniRg doctor as hysterical, since the patient could obviously see.

63

CHAPTER V

ABNORMAL PERSONALITIES

PROBLEMS OF CLASSIFICATION OF
MENTAL DISORDERS

The classification of psychiatric disorders is difficult because classiiica*
tion should be based on aetiology and in many psychiatric disorders
there is no clear aetiology. The standard approach in English-speaking
countries is to divide these disorders into neuroses and psychoses.^^

1. Insight. — ^The neurotic has insight, buT the psychotic has not.

O^ection . — Some hj’sterics have no insight, while some depressivca

(autonomous dysthymics), some young intelligent schizophrenics, and
quite a number of arteriosclerotic dements realize that they are mentally

ill.

2. Involvement of the Personality. — In neurosis the personality
is only partly involved, but in psychosis the whole persortality is
distorted by the illness.

Objection.^^Somt b)‘steric 3 and obsessional neurotics have personal'
ities >^hich are totally involved in the illness, tvhlle some manic-
depressives manage to live trith their illness.

3. Social Adaptation. — ^The neurotic makes a fair social adjustment,
but the psychotic is unable to do so.

Objection , — Hysterics may be unable to work, while some depressives
and paranoid schizophrenics can.

4. The Reality of Subjective Experiences. — ^The neurotic can
distinguish between his subjective experiences and reality while the
psychotic cannot.

Objection . — Some h^terics live in a world of fantasy, while some
depressives (autonomous dysthymics) can distinguish between their
inner experiences and reality.

5. The Reality of the Environment. — ^The psychotic constructs
a false en\'tronment, but the neurotic does not.

Objection . — Some hysterics and obsessional neurotics live in fantastic
environments of their o\>ti creation, while delusional reconstruction of
the environment does not necessarily occur in depression (autonomous
dysthjinia).

6. Disorder of Drives. — In psychosis there is a gross disorder of
drives including that of self-preservation, whereas this does not occur
in the neuroses.

64 AN OUTLINE OF PSYCHIATRy

Objection . — Some neurotics commit suldde and patients with
anorexia nervosa starve themselves to death.

7. Uoderstandabiiity. — A psychosis is a mental illness in which a
marked personality change occurs, which cannot be interpreted as an
understandable development of the personality or as a reaction of the
personality to psycholo^cal trauma.

If we accept this last definition tve are also assuming that there is a
physical change in the nervous system which causes the psychoses.
This leads us to the definition of a psychosis as a psychiatric illness
resulting from a physical chwgc in the brain. This would mean that
a mild depressive illness in which there were no delusions uould be a
psychosis. This would confuse English-speaking psychiatrists who
expect to find delusions in a psychotic depression. Non-psychotic
psychiatric disorders can be regarded as variations in human existence
in which the symptoms and the signs arc quantitative deviations from
the mean. These states arc abnormal because the behaviour of the
patient deviates markedly from the average, but they are not morbid,
because there is no underlying disease process.

There are, therefore, three major groups of psychiatric disorder*:—

1. Organic states, where the illness is the result of a demonstrable
brain di»rder.

2. * Functional psychoses’, in which a definite break has occurred in
the life pattern, which cannot be understood as a reaction or a develop-
ment of the personality. These illnesses— schuophrenia and the
affective psychoses — are probably the result of special disorders of the
brain.

3. Variations of human existence, which deviate from the mean
quantitatively but not qualitatively, and produce a disorder in the
individual and/or society, so that treatment is requested by the patient
or society.

Most English-speaking psychiatrists arc not familiar with this
classification and regard the conditions mentioned in paragraph 3 as
illnesses, which can be classified into neuroses and psychopathic
personalities. The neuroses are then classified into hysteria, anxiety
states, and obsessional neuroses. In this book neuroses vvill be regarded
as psj'chogenic reactions or personality developments, which arc
xmderstandable responses of normal, accentuated, or abnormal
personalities to stress.

PSYCHOPATHIC PERSONALITIES

\Vhite English-speaking p^chtatr^ have regarded psychopathic
personalities as fundamentally antisocial, most German-speaking
psychiatrists have followed Kurt Schneider and regarded them as

ABNORMAL PERSONALITIES

65

abnormal personalities who suffer from their abnormality or cause
society to suffer because of their abnormality. However, even among
German-speaking psychiatrists, the term ‘psychopathic personality’
has acquired a pejorative meaning. Recently both Petrilowtsch and
Leonhard have pointed out that the negative aspects of the psycho-
pathic personality have been overstressed and that the same psychopath
who is a burden to society can, given the right circumstances, become
a worth-while member of society. Leonhard and Petrilowitsch do not
use the terms ‘psychopathic personally' or ‘psychopath’, but use the
term ‘abnormal personality’ insW^ Unfortunately, the terms
‘psychopathic personality’ and ‘psychopath’ are firmly embedded in
the minds of most English-speaking psychiatrists, most of whom would
agree with the views of the late Professor Sir David Henderson.

SIR DAVID HENDERSON’S VIEWS

Definition. — Psychopathic personalities have the foIIoTring features
(Henderson and Batchelor, 1962): —

1. They are abnormal in their emotional reactions and conduct from
childhood or early youth.

2. They show no gross intellectual defect.

3. They only episodically reach a degree of abnormality amounting
to certifiable insanity.

4. They do not leam from experience, so that punishment is of no
avail.

5. They lack judgement, foresight, and ordinary prudence.

Classification.—

1. Aggresttve Psychopaiks.^They are violent to themselves and/or
to others. Calmness n-ith complete insight may follow a violent episode
which seems to clear the air like a fit in some epileptics. They are
emotionally cold and insensible to the fcclings.of o^ers. They have no
remorse.

VariabU features are: Suicide; homicide and assault; alcoholism and
drug addiction; sexual perversions and promiscuity; criminal activities;
recidivism.

2. Inadequate Psychopaths . —

Unelassifiable inadequates: These consist of petty delinquents, who
indulge in thieving, Ijing, and swindling, and pathological liars. They
may be placid, easily su^estible, rather charming people who readily
accommodate themselves; or they may be cold, frigid, apathetic
individuals who are utterly detached and individualistic.

Personalities scith features similar io psychiatric illnesses'. These
comprise schizoid personalities, who are quiet, asocial, and withdrawn;
h3r8terical 'personalities, who are histrionic and attention-seeking;

5

66 AN OUTLINE OF PSYCHIATRY

cycloid pcfSOTialities, ivith a teodcncy to marked mood swings; and
paranoid personalities, who are suspidous and naistrustful.

3. Crealivt Psy'chopaihj . — ^Manj famous people have psychosexual
immaturitj’, emotiond imlabiliiy, and marked bdividuality. These are
alleged to be creative psychopaths, for e;xamp]e, Joan of Arc, Napoleon,
and Lawrence of Arabia.

Discussion. —

Possible Organfc Basis . — ^Young post-cncephalitics may behave just
like aggressive psychopaths, which suggests a possible physical basis
for psychopathy. Many psychopaths, especially of the aggressive type,
have abnormal E.E.G.S of an immature variety, but not all people with
immature E.E.G.8 behave badly.

Immaturity . — Much of the abnormal behaviour can be understood
as due to immaturity, and this fits the E.E.G. findings. Psychopaths
usually improve as they grow older.

Discussion oj Henderson's Classification . — Aggressive individuals fitting
Henderson’s description of an aggressive psychopath do occur. The
term ’inadequate psychopath* is open to the objection that every
inadequate, ill-adapted person is therefore a ptyehopath. Some
schizoid, hysterical, cycloid, and paranoid personafities do, in fact,
make quite reasonable adjustments. ‘Creative psychopath* is a poor
term because all ouutanding people must be abnormal in a quantitative
sense.

The Criminal . — Some criminals are produced by a criminal sub-
culture and yet conform to Henderson’s criteria for psychopathy. It is
not justifiable to regard these criminals as being ill. Anti-social
behariour is a poor criterion for classification, because ail varieties of
personality can be found among criminals. It is not difficult to find
ananka&tic, paranoid, and hysterical personalities in prisons. The
anankast, for example, can be 3 trustworthy upright member of society
or he can be a highly skilled and meticulous safe-breaker. It is pre-
ferable not to use the terms ‘psychopathic personality' and ‘psycho-
path’, but to use the terra * anti-sodal abnormal personality’ and then
go on to specify the variety of abnormal personality.

THE TREATMENT OF PSYCHOPATHIC PERSONAUTIES

Individual Therapy. — On the whole these patients do not respond
well to individual psychotherapy, because they act out in the treatment
situation and cannot be confronted with their abnormal behaviour in
the way in which the neurotic has to lace his symptoms. Nevertheless, an
attempt should be made to get the patient to understand his personality
difficulties and make allotranws fijr them. In the case of the ‘episodic
psychopath’ superfidal psychotherapy and environmental adjustment

ABNORMAL PERSONALITIES 67

are necessary during a crisis. Howcwr, it is important that the
psychiatrist should not allow the psydiopath to use psychiatric illness
to escape from the natural consequences of his actions.

Group Therapy. — ^Thb appears to be a more rational treatment of
the psychopath, because his unusual behaviour is much more obvious
in the group situation and he can team to cope with it in the social
environment of the group.

Out-patient group therapy may be useful for psychopaths who are
not too disturbed. In more severe disorders in-patient group treatment
in a special unit is indicated. It is best not to admit these patients to
an ordinary mental hospital, because they usually exploit and disturb
neurotic and psychotic patients.

Criminal Psychopathic Institutions. — ^These are special peno-
logical institutions in which individual and group therapy can be carried
out. In some countries the courts, 00 psychiatric advice, can commit
a criminal psychopath to a special Institution for an indefinite period.
The prisoner can then only be discharged by a review board after a
prolonged period of trial leave. Recently an institution has been
opened in England for the treatment of criminal psychopaths. In
EngUsh and Scots Law there is no indeterminate sentence, although in
England, under the Criminal Justice Act (194S), a sentence of up to
fourteen years preventive detention can be imposed on a habitual
criminal. XJnforturutely this excellent provision was not properly
implemented by the establishment of a special rehabilitation unit for
the preventive detention prisoners.

Guardianship. — Many countries have legal provisions for guardian-
ship designed to prevent unstable or mentally ill individuals from
exposing themselves and their families to social distress. The English
Law allows a court to place a psychopath under guardianship after he
has been convicted of an offence. It is possible that this may be done
in some cases of psychopathy in order to supervise the patient and
prevent him from getting himself into difficulties.

ABNORMAL PERSONALITIES

The abnormal personality has one or more personality traits which are
outside the intensity of the nonnal range. Ideally we should be able to
measure personality traits and be able to estimate precisely which traits
areabnormalinany^vencase. Unfortunately,nomeasuresof personality
traits are suffidently reliable to allow us to classify abnormal personalities
in a scientific way. Psychiatrists have described types of abnonnal
personality based on clinical experience and have later tried to explain
them as exaggerations of a personality trait. Schneider, (1958) has
described ten tjqies which arc generally accepted by German-Baking

68

AN OUTtINB OF PSVCrriATRy

psychiatrists although modifications have been suggested, e.g., Leonhard
(1965) and Petnlowitsch (1566). The dominant abnormal personality
trait is used to designate the type, but a sulyect^may have more than
one abnormal personality trait, so that at limes m ixed types occur. It
must be remembered that the abnormal personality type is not a diag-
inosis, but merely a convenient way of indicating how the abnormal’
\pcrsonality is likely to behave.

The abnormal personality has one or more personality traits which
are quite outside the normal range, but there are normal personalities
who have ^^ell-marked personahty traits which are at the outer limits
of the normal range. Leonhard has called these subjects ‘accentuated
personalities’, in order to indicate that ih^ have personality traits
^^hich are not quantitatively abnormal but which must be taken Into
account when evaluating the individual’s reaction to psychological
trauma.

LEONKARD’S CLASSIFICATION OF
ABNORAtAL PERSONiUJTlES

The EpUeptold Personality.— These subjects react explosively
depending on their moods and drives. \Vhen something does not suit
them they flare up and react impulsively. They are, however, not
necessarify upset by trivialities and may at rimes be emotionally
indifferent. \Vhen they are frustrated or in a bad mood severe excite-
ment may occur. They change their Jobs frequently and tend to
dnnk to excess. There is no relationship behvecn this type of person-
ality and epilepsy. \\’hen the epileptoid trait is definitely present, but
not outside normal limits, the accentuated personahty can be called an
unconlroUsd personality. This type of personality reacts in an impulsive
way, but is not antisocial, although under the influence of alcohol the
uncontrolled personality may become brutal and excited.

The Anankastic Personality. — ^This type of personality is usually
called an obsessional personality m ilritain and zeompulsire personality in
the United States. The anankast is a rigid inflexible person who loves
order and discipline for its own sake. He is usually persistent when
faced with dilHcuIltes, but often finds it difficult to make decisions. He
may become ve^ anxious or angry when his routine ts disturbed. Hb
pedantic ah 3 self-righteous attitudes may upset his colleagues, who
may then react with irritation or obstruction. This leads the anankast
to feel that he b not appreciated and that people are laughing
at him.

The anankast is usually a Wghly respectable person and a living
example of moral rectitude. Often, however, he has very vivid sexual
fantasies, which may lead to perverse or prombcuous behaviour.

ABNORMAL PERSONALITIES 69

Some anankasts have minor obsessional symptoms such as counting
and touching compulsions and the need to check and recheck.

When anankastic traits are definitely present, but within the normal
range, the subject can be s;ud to have an overprecue personality. He is
more careful and responsible than the average person, but is not given
to doubt or excessive brooding. He is usually appreciated for his
conscientiousness, but is often regarded as being pedantically precise.

Only a few anankasts develop severe obsessional states. Depressive
illnesses (autonomous dysthymia) are not uncommon in this type of
personality. Chronic anxiety states and hypochondriacal develop-
ments may occur in anankasts.

Psychoanalysts have called this type of personality anal, because
they believe that rigid toilet training at the anal stage of libidinal
development modifies the ego and produces orderliness, frugality, and
obstinacy. Orderliness is the result of the parents’ insistence on
regular bowel actions, while obstinacy is learned in the struggles about
bowel regulation. Frugality or meanness is supposed to arise from the
infant’s desire to retain his faeces, which b motivated by the fear of
losing something valuable and the erotic pleasure produced by retaining
the faeces.

The Hysterical Personality.— Jaspers pointed out that the
essential feature of this type of personality \vas an excessive need for
appreciation. If patients of this kind do not get the appreciation which
they need, they overact or behave in a way which leads other people
to become concerned about them. Another way of looking at the
hysterical personality is to regard him as having the ability to repress
everything which is unpleasant for him. While a nonnal person would
have to lie consciously in order to achieve some egotistical goal, the
hysterical personality can repress the objective facts and tell lies without
being consdous of doing so. As they are no longer consdous of the
truth, pathological liars and swindlers are able to live their lives
convindngly. If the pathological liar has a very vivid fantasy life, he
may tell the most outrageous lies. Thb has been called psetidologia
fantastica, but it is merely one variety of hysterical personality. Some
pathological liars frequent hospitals, complaining of symptoms of
abdominal disease, and may induce unsuspecting surgeons to operate
on them. These patients usually have operation scars on the abdomen
and give melodramatic accounts of their previous illnesses and opera-
tions. This has been called the 'Munchausen syndrome’, but it is only
one variety of hysterical swindling. Some hysterical personalities want
to be treated as important people and therefore give themselves famous
names or titles or they dress up in lugh-ranking officers’ uniforms.
Others take advantage of their ability to tell plausible lies and become

70 AN OUTLINE OF PSYCHIATRY

confidence tricksters. Instead of repressing objective facts and lying
the hysteric may repress the fact that he is imitating a disease and
present physical or mental symptoms.

The hysterical personality may produce a short-term solution to his
problems by repressing facts, but in the long run the solution often
produces a good deal of trouble. An hj-stcrical paralpis may solve a
problem, but the life of a chronic invalid has many disadvantages.

So far only the negative aspect of the hysterical personality has been
considered, but this is a one-sided view. The hysteried gift for
expression may show itself as outstanding acting ability. The good
actor does not merely represent the part but he lives it. Here we see the
positive side of the personality trait which is seen in its negative aspect
in the hysterical sandier. Both the actor and the swindler can forget
who they are and liw a part which others can only imitate. Creative
writers often have hysterical truts, which increase their powers of
fantasy, because they are able to shut thcmselv'es off from reality and
live in the world of imaginau'on. Other traits and attitudes determine
whether the hysterical trait has a positive or a negative effect The
hysterical personality with high etldeal standards does not allow the
mechanism of repression to be used for dishonest purposes. There is,
hotvever, alwajx the danger that individuals with this type of person-
ality may use their ability to repress in order to avoid something
unpleasant.

A person who has hysterical traits which are near the outer limits of
the normal range can be said to have a dmmstrative personality.
Personalities of this kind are able to adapt readily to any sodal situation
and to present themselves in the most favourable light. They know how
to produce a good impression on other people and how to evoke
sympathy and compassion in others. When faced with situational
difficulties these personalities may show very marked demonstrative
behaviour.

Paranoid Personalities. — UTiile the hysterical has an eveessive
need for appreciation, the paranoid personality has a need to be
recognized for what he considers to be his true worth. He tends to
overvalue his abilities and readily attributes his failures to the ill will
of others. There is an excessive sensitivity to supposed or actual
injuries and sights. This type of personality has acquired its name
from the fact that delusion-like ideas may develop in personalities of
this kind as a result of conflicts between the individual and the environ-
ment. These patients may believe that they are victims of intrigue
although there is no objective evidoice. Leonhard believes that there
is an abnormal persistence of the eflects of cmotiojialJy loaded experi-
ences in these personalities. Feelings caused by these experiences tend

ABNORMAL PERSONALITIES ?!

to accumulate and bias thought. The difficulties of e\er>'day life
usually increase these feelings, and this results in an abnormal attitude
of self-importance, which repeatedly meets resistance from the environ-
ment. The paranoid personality becomes preoccupied with striving to
succeed despite his environment and to raise himself above it as much
as possible.

\Vhen the paranoid trait is only moderately expressed and is still
within the normal range, the personality may be called overpersutent.
This type of person has an ambitious striving and is very sensitive to
criticism. He is usually easily offended and may be inclined to fight
for the rights of others.

The Reactive-labile Personality. — ^While the paranoid person-
ality is sensitive to critidsm, the reactive-labile personality is emotion-
ally seiujtive and reacts excessively to emotionally charged situations.
He is very easily moved by both happy and sad events, so that he
becomes happy and sad much more easily than the average person.
These personalities are much more likely to develop reactive depres-
sions than the average persort.

Milder degrees of mood lability, which are not outside the normal
range, occur in motive pertonalities, who are not only easily depressed
by their own misfortunes, but have a good deal of compassion for
others. They weep easily and cannot see a moving film without tears
coming to their eyes. It is difficult to decide if they feel more deeply
than others or if they merely have an bereased emotional responsiveness.

The Cyclothymic Personality.— Like the reactive-labile person-
ality the cyclobymic is abnormally sensitive to external influ-
ences, but he is not reactive to the same degree. External events act
as releasing agents rather than causes of mood change in cyclothymic
personalities. Their abnormal readiness to become cheerful or sad
arises from an internal lability of mood which may be set off by some
external stimulus. The mood tends to continue for some time and
outlast the immediate emotional upset. Sometimes the variations in
mood are entirely the result of internal events so that the cyclothymic
may become depressed or elated for hours, weeks, or days for no obvious
^reason. Many patients with affective psychoses have cyclothymic
personalities, but this type of personality can occur quite independently
of affective psychoses.

Some cyclothymic personalities have marked variations of mood
ranging from rapture, on the one hand, to utter despair, on the other.
Leonhard considers them to be reminiscent of anxiety happiness
psychosis, but this type of personality is frequently found in actors and
poets, who because of their emotional excitability are able to put them-
selves whole-heartedly into the artistic production which they wish to
present

72 AN OUTLINE OF PSYCHIATRY

When there are mild swings of mood between depression and
elation, which are just within the normal range, then the accentuated
personality can be called a moad-hUnle pertonalUy.

The Subdepressive Personality. — The outstanding features of
this personality are those of an attenuated depressive illness. There is a
general pessimism, and excessive seriousness, and a slowness in
thought and activity. Individuals with this type of personalitj' do not
necessarily suffer from depression or mania. When the depressive
traits arc marked but not outside the normal range the personality can
be called overseriouj.

The Hypomanie Personality.— Cheerfulness, overactivity, and
prolixity are the characteristic features of this type, but one or the other
of these features may be more pronounced, so that quiet cheerfulness
or cheerless ovcractivity may occur. If the hypomanie traits are
pronounced, but within normal Umits, the personality can be called
overaelive.

The three varieties of personality which resemble attenuations of
the affective psychoses have been sharply separated from each other in
the above discussion, but transitional fonns may occur. The sub*
depressive may become elated for a time, the hypomanie may develop
depression, and the cj'clothymic may have prolonged periods of elation
or depression.

The Anxious Personality. — ^The subdepressive and thec>'ctotbynuc
in the depressive phase may be unduly aaxious, but anxious person-
alities can be found which cannot be dassihed into any of the t}'pes
which have been discussed so far. Subjects of thia kind have many
fears as children and in adult life they are easily frightened and tend to
avoid arguments.

Mixed Types. — Leonhard believes that combinations of abnormal
or accentuated personality traits can occur and the traits can sometimes
modify each other. For example, he suggests that anankastic and
h)-8terical traits appear to compensate each other.

OTHER PERSONAUnr’ ’nTES

Some personality types described by Schneider are not accepted by
Leonhard. These are the sensitive, fanatical, aifectionicss, weak-willed,
and asthenic personalities. The sensitive personality believes that he
13 held back by some abnormality of his body, personality, or social
status. He feels that were it not for this fault he would achieve much
more. Kretschmer behcred that peisanalnJes of this kind could
develop a paranoid psychosis, which he called 'sensitive delusions of
rcVcrehce'. The fanatical psychopath is dominated by overvalued ideas
about his personal affairs or social events. He may be expansive and

ABNORMAL PERSONALITIES 73

proclaim his views loudly or he may pursue his ideas in a quiet deter-
mined way. The affectionless personal!^ has no feelings for others.
He lacks any sense of shame, self-respect, and conscience. The weak-
willed or irresolute personality is unable to resist any influence, good
or bad. The asthenic personality has apermanentfeelingof insufficiency
of a psychological or phj-sical kind. This leads to persistent self-obser\’a-
tion which in turn leads to psychological or physical sjTnptoms.

PSYCHOANALYTIC THEORY:

THE CHARACTER NEUROSES

In neurosis repressed material breaks through into consciousness in
a form which is foreign to the ego, but in character disorders the form
is not alien to the ego. Character traits are of two types: sublimination
of instinctual drives, and a part of a countercathectic measure which
keeps certain instinctual drives in check. The first type is not patho-
logical, but those in the second type can distort social relations severely.

It is possible to classify character Qrpes according to the stage of
libidinal development which had the most effect on the character.
Thus there is the oral type wWch may be frustrated or gratified. The
gratified oral type is optimistic, self-assured, and generous, while the
frustrated variety is pessimisu'c, impatient, irritable, selfish, and
demanding. Marked exaggerations of these oral types are found
among antisocial personalities. The anal character is orderly, obstinate,
and stingy, while urethral traits are impatience and ambition.

74

CHAPTER VI

PSYCHOGENIC REACTIONS,
PERSONALITY DEVELOPAIENTS, AND NEUROSES
The nonnal, accentuated, and abnormal personalities respond to
psychological trauma in many different svays. The symptoms and the
severity of the psychiatric disorder depend on the previous personality’
and the nature and extent of the psychological trauma. Sometimes the
response is an acute reaction which dica a^^-ay in a few days or weeks.
In this case we are dealing with a psychogenic reaction. In other cases
the disorder may run a chronic course and last for months or years.
Sometimes the abnormal response begins slowly and flurtuates in
severity, but over a period it steadily becomes worse. This is a
personality development and is the result of a chronic interaction of an
abnormal personality and the environment. The distinction between
a personality development and a psychogenic reaction is not always a
sharp one because a patient may have what appears to be an acute
psychogenic reaction but it may continue as a personality development
as a result of an unfavourable environment.

Psychogenic reactions and personality developments can be classihed
in the follow tng way; —

1. Anxiety reactions.

2. Fright reactions.

3. Goal-directed or hysterical reactions and developments.

4. Obsessional or anankastic reactions.

5. Depressive reactions.

6. Hypochondriacal developments.

7. Paranoid reactions and developmenta.

ANXIETY REACTIONS

Symptoms of Anxiety. — ^Anxiety occurs in many different
psychiatric disorders. It is important to recognize anxiety symptoms,
because the anxioiis patient often complains of the physical accompani-
ments of anxiety and not of anxiety as such. The presenting physical
symptoms of anxiety are deteimmed by the patient’s previous experience
of disease and his constitutional predisposition to different patterns of
autonomic overactivity.

PSYCHOGENIC REACTIONS 75

Cardiovascular Symptoms, — Palpitation is the most common symptom
of this kind and is a sensation of forceful beating in the praecordia!
region. In severe anxiety the sensation may spread into the neck and
upper abdomen.

Respiratory Symptoms. — Rapid breathing is common in anxiety, but
a few patients develop the hypoventilation syndrome. In this case the
prolonged deep breathing leads to a loss of carbon dioxide and a
respiratory alkdosis, so that the patient feels weak and dizzy and has
paraesthesiae in the hands and feet. Some chronically anxious patients
have the syndrome of left inframammaiy pain, when they complain of
aching and soreness in the lower part of the left breast and difficulty in
getting enough air into their lungs.

Gastro-intestinal Symptoms. — Dryness of the mouth is often caused
by anxiety and can give rise to mild difficulty in swallowing. The
commonest abdominal symptom of anxiety is an unpleasant churning
sensation in the epigastrium. This may lead the patient to believe
that he has ‘indigestion’. In severe anxiety, spasm of the pylorus and
reversed peristalsis may give rise to vomiting. In less severe anxiety the
patient may feel continuously nauseated. Anxiety often leads to a loss
of appetite, but a few anxious women overheat and Hnd that eating
allays anxiety to some degree. Some anxious patients have an increased
motility of the gastro-intestinal tract and may complain of abdominal
distension after meals and frequent soft stools.

Genito-urinary Symptoms. — Increased frequency of micturition may
result from anxiety. Sexual drive is usually diminished, so that
impotence or frigidity often occurs. A fe^v patients have an increase in
sexual drive and some anxious males have erections when their anxiety
becomes severe.

Motor Symptoms. — ^Anxiety may cause a general increase in the tone
of voluntary muscles, which is experienced by the patient as a feeling
of tension. Tense patients often complain of being weak and exhausted.
This can be regarded as the result of excessive muscular tension, but
it has been suggested that adrenaline secreted by the adrenal medulla
during chronic anxiety may reduce muscular contractions. Tension in
the frontal and temporal muscles may cause a tension headache which
is experienced as a tight band across the forehead. Typically the
patient tvith an anxiety state complains of frontal headache, while the
patient %vith a depressive illness tends to complain of occipital headache.
Anxiety often produces tremor, which is usuai/y most marked in the
hands and wltich increases during voluntary movements or when
attention is drawn to it.

Psychological Symptoms. — Anxiety causes increased distractibilit}’,
so that the patient is unable to think clearly or to concentrate on an

76 AN OUTLINE OF PSYCHIATRY

intellectual task. Difliculty in concentration leads to a poor memory,
because the patient is unable to attend to what is going on around him.
Poor memory and difficulty with intellectual tasks may lead the
intelligent introspective patient to think that he is going out of his
mind. Some anxious patients feel bewtldcrcd and pcqilexed, while
others complain of a ‘muzzincss* or feeling of fullness in the head.
Dizziness or a sense of unsteadiness may be the presenting complaint
of an anxious patient. The physiological basis of this symptom is not
clear, but in some cases it appears to be an accentuation of normal
postural dizziness which occurs when the subject rises from a sitting
position-

51e<p.*-Anxious patients have difficulty in falling asleep. ^Vhen
anxiety is severe the patient may have frightening dreams from which
he awakes in terror.

THE CLASSinCATION OF ANXIETY STATES

Anxiety states can be classified as follows:—

1. Acute anxiety states.

a, Acute traumatic anxiety state.

h. Acute reactive anxiety states.

e. Acute exacerbations of chronic anxiety states.

2 . Chronic an.xicty states.

a. Chronic reactive anxiety state.

b. The anxious personality.

c. The chronic hysterical anxiety state.

d. The phobic anxiety state.

I. Acute Anxiety States. —

a. Acute Traumatic Anxiety Slate. — The subject undergoes some
terrifying experience which threatens his life. At the time be is angry
and hostile towards someone whom he blamea for the inddent or he
behaves in a way that he is subsequently ashamed of.

He becomes tense, anxious, and tremulous. He is easily startled and
his sleep is broken by anxious dreams concerned with the traumatic
event. Treatment consists in abreaction which allows him to re-live the
event Recovery occurs so long as there is no marked secondary gain.

b. Acute Reactive Anxiety Stater . — Moat individuals become anxious
when their usual adaptation is disturbed. The severity of the anxiety
depends on the severity of the stress and the resilience of the personality.

The person may be quite consdous of his problem, e.g., manta!
difficulties, but may not relate Ws nervous symptoms to his legitimate
worries. The patient must be persuaded to face hb problems and try to
solve them. He should not be aQowed to regard himself as ill, but as
having a normal reaction to difficulties. Sedation should be given to tide
the patient over a severe crisis, but must not be continued for v’ery long

PSYCHOGENIC REACTIONS 77

or the patient may become habituated or continue the sedation %vithout
trying to solve his problem.

c. Acute Exacerbaiiom of Chrome Anxiety States. — ^These are usually
excessive reactions of inadequate persons to stress.

2 . Chronic Anxiety States. — ^Therc is obviously some overlap
betw’een these chronic states.

a. The Chronic Reactive Anxiety State. — Here the subject is in a situa-
tion which is upsetting but irremediable. Sometimes the situation is
partly of the subject’s own making or failure to solve it is due to some
personality abnormality. Thus in some cases the situation plays the
most important part, while in others the personality is more important.

b. The Anxious Personality. — In some people chronic anxiety is a
part of an inadequate, insecure personality. Many anankastic (or
obsessional) personalities (see p. 68) arc very tense, anxious people.

c. The Chronic Hysterical Anxiety Stale. — ^Acute anxiety reaction
occurs for some reason and is then used unconsciously for gain,

d. The Phobic Anxiety State. — Here the patient is frightened of some
situation. The commonest phobia is agoraphobia or fear of open
spaces. The patient with this fear may be unable to leave his home on
his own, but can do so when accompanied. Phobias of this kind are
often learned. The agoraphobic may initially be anxious for some
reason and have an attack of anxiety in a public place, which causes a
fear of going out alone. Sometimes there is secondary gain, e.g., the
agoraphobic woman may dominate her husband, because she can only
go out with him and he must stay with her at night because she also
cannot be left alone in the house at night. The phobic anxiety state
responds best to behaviour therapy (q.v.).

The Diagnosis of Anxiety States. — Many acutely depressed
patients (autonomous dysthymics) have severe anxiety which may
overshadow the depressive symptoms. Acute anxiety states in the
absence of some severe traumatic event or unpleasant life situation
should be investigated carefully for depressive mood, diurnal variation,
and the typical sleep disorder.

FRIGHT REACTIONS

These reactions follow a catastrophic experience, such as an earth-
quake, an explosion, or a traffic accident. The symptoms are very
variable. Sometimes there is stupor with mutism. Sometimes there is
panic-stricken behaviour which may put the subject into greater
danger. There may be a euphoric rrrood with pressure of speech and
ovcractivity or a twilight state with nurked restriction of consciousness.
The fright reaction lasts for a short time, but it can pass over into an
hysterical reaction.

78 AN OUTLINE OF PSTCIITATRY

HYSTERICAL OR GOAL-DIRECTED REACTIONS

Definition^ — ^The presence of mental or physical symptoms for the
sake of some advantage although the patient is not fully aware of the
motive.

The term ‘hysterical’ is used in Aree senses. It may be used to
designate a goal-directed reaction or what is ^ed an ‘hysterical
illness’ in the English-speaking world. The term may also be used to
designate a type of personality or it may be used for importunate
attention-seeldng behatnour.

Hysterical illnesses have been subdivided into conversion hysteria
and anxiety hysteria.

Conversion Hysteria. — A mental conflict is converted into a physical
or mental symptom. If the conversion Is complete all anxiety due to
the conflict disappears and there is belle indifference. ’

Anxiety Hysteria. — In the classic Freudian sense this is the restric-
tion of the anxiety produced by a conflict about a given situation, so that
the patient develops a phobia. Unfortunately, both phobic states and
obsessional states with phobias were included in this illness. Anxiety
hysteria has also been used to designate:—

1, Illnesses in which conversion symptoms and anxiety are present

2. lUnesses in which anxiety symptoms are unconsdously used for
the sake of some advantage.

Anxiety hysteria is therefore a term which is best avoided.

In th^United States the term eonversion reaction is used for hysterical
reactions In which ph>‘sical symptoms occur, while the term dissociative
reaction is used for those hysterical reactions in which psychological
' symptoms are present. This is not justifiable, because, as we shall see,
Janet used the concept of dissociation to explain all hysterical symptoms.

Aetiology. —

Parental Influence. — Hpterics tend to have hysterical or anxious
parents.

Hysterical parents may teach their children histrionic behaviour or
the pattern of hysterical conversion.

Intelligence, Education, and General Bael^ground, — Dull and unsophis-
ticated persons are likely to have well-marked hysterical symptoms when
in conflict.

In more intelligent individuals and in cultures in which ‘neurosis’ is
respectable, h3rsterical symptoms take the form of anxiety and phobias.
Iln World War I many neurotic Bridsh soldiers had well-developed
conversion hj'steria, but in World War JI their sons had ‘anxiety states*.

Physical Illness. — ^This may suggest to the patient the idea that illness
is a solution to h'ls problem, leading to a hysterical exaggeration and
prolongation of the disability originally produced by a physical disease.

PSYCHOGENIC REACTIONS 79

Disseminated sclerosis is usually associated with a hysterical
exaggeration of the physical symptoms. Temporal lobe lesions are also
often complicated by gross hysterical ^mptoms.

Psychological TTheories. —

Janet't Theory of Dissociation. — Fatigue, puberty, physical disease,
and emotion can all lower psychological tension. This lowering of
tension in bj’steria affects only one function which disappears from
consciousness, i.e., it b dissociated.

The subject has a conflict which produces anxiety, allowing dissocia-
tion to occur. A mental representation of a bodily or mental function is
split off from consciousness. Physical or mental illness is then accepted
as the cause of the distress produced by the mental conflict, so that the
anxiety is replaced by belle indifference.

Freud's Theory. — The fixation point is at the genital stage of libidinal
development, so that when introversion occurs due to loss of a loved
object {see p. 28) the freed libido regresses to reactivate the unsolved
conflicts in the Oedipal situation.

The incestuous love object is symbolized by the symptoms, or the
subject identifies with it, so that there is a somatic dramatization of an
unconscious fantasy.

The hysterical sjTnptom may symbolize the Oedipal conflict or the
current conflict, or may be based on some mild organic defect The
hysterical phobia symbolizes the current conflict and the Oedipal
conflict.

Primary gain: The symbolic solution of the current conflict leads to
a relief from anxiety. This is the primary gain.

Secondary gain: The symptom itself may produce fortuitous
environmental changes which are advantageous to the patient. This is
the secondary grin and may be so great as to provide an unconscious
motive for continuation of the hysterical symptom after the current
conflict has been resolved.

Any symptom due to mental or physical illness can be used
unconsciously for secondary gain.

Symptoms. —

General Points. — Any physical or mental disorders which can be
^imagined by a normal person can be hysterical symptoms. ’ '

Negative phyrical findings arc not di^nostic of hysteria, since it can
be some time before unequivocal indications of physical disease appear.
Hysteria is a positive diagnosis, so that the psyi^iatrist must be able to
show that the symptom is unconsdously motivated. Until he can do
this he should not assume that the iUncss is hysterical merely because a
general phpidan cannot find any positive signs. Symptoms can be
sensory, motor, or mental. '

So AN- OUTLINE OF PSyCHIATRT

Sensory Symptom, — ^These consist of blindness, deafness, anaesthesia,
and pain. They tend to occur under great stress and among the
unsophisticated. Hysterical abdominal pain may result in multiple
partial cviscerations by uncritical surgeons.

Motor Symptom. — ^These take the form of paralysb, spasms, and
tremor. When the patient tries to move his 'pa^ysed limb’ the
antagonists contract as well as the appropriate muscle groups, and
associated movements occur in the pai^ysed limb when the normal
one is moved. Hysterical Hts occur when there is an audience and
consist of a thrashing about of the limbs with the eyes firmly shut, quite
unlike the tonic and clonic contractions of the epileptic. Mild blackouts
may be difficult to diagnose and it must be remembered that a single
negative E.E.G. does not exclude epilepsy.

Mental Symptoms . —

1. Amnesia, fugues, ttsilight states, and multiple personalities: Loss of
memory may only be partial when it affects some memory which is very
prinful or it may be total when it affects all knowledge of the past and
the personal identity. This total lack of memory is in striking contrast
to the preservation of the ability to deal reasonably with the immediate
enviroament, whereas a dement with the same degree of memory loss
cannot fend for himself.

The hysterical memory loss is usually associated with wandering.
This is a hysterical fugue or wandering state. During such states
the subject sometimes re-enacts traumatic events in a very dramatic
way.

The boundary line between hysteria and malingering in these states
is impossible to define. Multiple personalities arc artefacts created by
hysterics with the assistance of gullible psychiatrists.

2. Hysterical pseudodemeniia and Gamer states: Ganscr described a
twilight state in prisoners, in which there was clouding of conscious-
ness and approximate answers. Other psychiatrists claimed that true
clouding of consciousness did not occur in this condition. In hysterical
pseudodementia the patient gives approximate answers in the absence
of any change in consciousness. Care has to be taken to distinguish
between approximate answers {Vorbtirtden) and paraphasic speech
disorder wWch may occur in generalized brain damage when it is
associated with clouding of consciousness. It is qucstionahle whether
the Ganscr state and hysterical pseudodementia should be regarded as
hysterical conditions. It seems much more logical to consider them to
be varieties of malingering.

3. Stupor: This usually occurs under severe stress. There is no
incoritinence and the patient will often eat when not observed,

4. Hysterical excitements {hysterical ‘ps^'ckoses'): These may be
short-lived outbursts of violence in hysterical psychopaths or excited

PSYCHOGENIC REACTIONS 8l

states with aggression and self-mutilation lasting for several months.
These latter patients usually are adolescent or young adult females who
have had a very disturbed childhood. They have vivid visual hallucina-
tions and slash their %vrists and forearms repeatedly. Despite the
severe excitement it b easy to make rapport with them.

5. Hysterical anxiety and depressive states: Here the patient reacts to
unpleasant situations with anxiety and/or depression. The symptoms
solve the situation to some degree so that they are continued because of
the secondary gtun, or they subdde and rcm»n as a symptom pattern
which can be used hysterically in the future.

In World War II British soldiers who became incompetent o%ving to
fear were evacuated with a diagnosis of nervous disorder. In many cases
the mental symptoms continued as an ‘anxiety state’ as long as there
was a threat of return to dangerous active service.

Special Varieties of Hysterical Reactions. —

Compensation Neurosis. — ^The desire for compensation and the anxiety
associated with the legal proceedings are responsible for the illness.
Other factors, such as unspoken (ear of dangerous jobs (e.g., a face
worker in a coal mine), and increasing difficulty in heavy manual work
with age may be brought to the patient’s attention by the accident and
'^ct as unconscious motivea for the neurosis, so that cure is impossibje. '
A pension rather than a lump sum is likely to continue the disability.

The symptoms are usually gross conversion hysteria mixed with
anxiety and depression. Anger and resentment are only just below the
surface. If there are no complicating factors recovery occurs after the
compensation Is settled.

Engagement Neurosis. — ^This is a neurosis or psychogenic reaction
which occurs in cither sex when firm plans have been made for marriage.

The personality is usually obsessional and often there is undue
dependence on an ovcrprotecUve mother.

Depression and anxiety are common symptoms, but gross hysterical
symptoms may occur. The intended spouse is told: ' I am ill, darling;
it would be unfair to marry you.’ He or she replies: ‘You are ill,
darling; you need me all the more. I will look after you.’ Thereisthus
no escape from the prospect of marriage.

'These patients dissociate their engagement from their illness, so that
the illness can be called hysterical, although in the absence of gross
conversion symptoms it can be regarded as a psychogenic reaction.

Anorexia Nervosa. — ^This is a failure to eat in adolescent and young
adult females. Apart from loss of appetite, the patient may make herself
vomit and hide food to avoid eating it. Despite the gross loss of weight
the patient is usually active. The periods cease and there is fine downy
hair over the back.

6

8z AN OUTLINE OF PSYCHIATRY

Treatment consists of adnusuon to hospital wth careful supervision
of feeding. Phenothiazines, such as perphenazine (fentazin) 16-24 mg.
in 24 hours, and modified insulin, will prevent the patient from vomiting
and help her to g^un weight by increasing the appetite.

It is often said that these patients equate fatness with pregnancy and
have fantasies of oral pregnancy. Certainly most of these patients axe
very immature women with a chslike of sexual matters.

Treatment.— This depends on the relative importance of the
situation and the personaJity in determining the illness. Situational
readjustment must be made where possible. Psychotherapy (see p. 214)
should be directed towards the discovery of the basic conflict and
patients should then be encouraged to make a rational solution of
their conflicts. In engagement neurosis both marriage and termination
of the engagement lead to a disappearance of the symptoms.

Prognosis of Hysteria- — TTiis depends on: —

1. Tlie current confiiet: If this is mild, then there is a vulnerable
personality, so that further illnesses are likely. If the conflict is insoluble
then the outlook is poor.

2. Secondary gain: If this is great recovery will be Jess likely.

3. Compeniatian: Psychotherapy will be useless until eompensation
is settled.

4. Previous personality. Recurrence is likely in hysterical personalities
who have suffered from previous illnesses.

5. Inlelligenee: Deep psychotherapy is useless in the dull and back*
ward, but su^estive therapy may be effective i/ the illness is no longer
useful. If the I.Q. is low and re-adaptation impossible then the outlook
is hopeless.

6. Age: Recurrence is likely if the patient has experienced repeated
hysterical illnesses until well on into middle life.

7. Duration of illness: The longer the illness has lasted the Jess the
likelihood of cure. By this tiofie secondary gain is very great and loss of
skill increases employment problems.

8. Presence of physicaliUnets: A physical defect enhances the patient's
belief in the physi^ basis for all his dis^ility. Many chronic invalids
are persons with slight physical illnesses with a marked hysterical
overlay. In Britain this means that they are able to draw sick benefit
and avill not be regarded as chronic unemployable misfits.

OBSESSIONAL OR ANANKASTIC REACTIONS

These are usually known in Britain as obsessional states or obsessional
neuroses. While for the sake of conristency these conditions are being
regarded as reacdons or developments of an abnormal personality, the
author has some reservations about the, because severe obsessional

PSYCHOGENIC REACTIONS 83

states cannot easily be regarded as variatioRS in human existence, which
arc only quantitatively abnormaL Apart from this, obsessional states
may occur in the absence of a marked obsessional personality.

Aetiology. —

The illness often begins in adolescence and childhood. Obsessional
states are often found in the parents — in 37 per cent, according to
Lewis (1936),

Ptyehoanalytic Theory . — 'The regression activates conflicts at the anal
sadistic stage of libidin^ development. In the infant at this stage there
is an alternation of love and hate towards objects. This alternation of
attitudes is revived by the regression. The reactivation of the conflicts
at the anal sadistic stage leads to the partial breaking through of material
produced by them, particularly aggressive fantasies. Some displacement
occurs, but the main mechanisms used are ‘undoing’ and isolation. In
undoing, the material representing the aggressive fantasies appears in
consciousness followed by its opposite which cancels out the effect of
the preceding anxiety-laden materiaL In isolation, different aspects of
an ambivalent attitude are separated in time and place.

The CUnIcfll Picture.—

Ofciejrice Compultive Behaviour . — The patient may have obsessional
ideas or images, in which case a phrase or vivid memory image dominates
his mind, or he may be troubled by obsessional impulses or compulsions.
He may be obliged to touch things or count things. Sometimes the
impulse is one of carrying out some antisocial act. In other patients the
obsession takes the form of a phobia and the individual is frightened
that something might happen, ^though his common sense telb him that
it is ridiculous. This often takes the form of fear of infection and
contamination, which leads to washing rituals and complicated patterns
of behaviour designed to avoid dirt and disease. Sometimes the
obsessions are complicated ruminations about one particular thing or
idea or very complicated trains of thought which have to be thought
through before the patient can be satisfied.

Often the rituals or rununations have to be repeated until the patient
is satisfied that they have been carried out correctly. In mild cases this
may be two or three times, but in severe ones the repetitions may be
much more numerous.

If the patient is prevented from carryingout his obsession he becomes
very tense. Some patients with veiy abnormal personalities may become
very angry and even violent when they are prevented from performing a
ritual or compulsion.

Anxiety and Deprejsion . — ^NVTien the obsessions are % ery marked the
patient is usually very anxious and depressed, because of the torturing
nature of the symptoms. In some patients the mood change seems to be

84 AN OUTLINE OF PSYCHIATRY

partly or wholly independent of the obsessional symptoms and is
associated with the typical features of depression (autonomous
dysthymia).

A few patients have manic-depressive illnesses and their obsessions
are much worse during the depressive phases and hardly noticeable in
the manic phases.

General Behaviour. — Some patients suffer from their symptoms,
while others involve their friends and relatives in their obsessional
rituals and may do this by threats as well as endearments.

Quite a number of these patients arc abnormal in other respects; In
particular they may be sexual perverts.

Usually obsessions do not lead to criminal behaviour. However,
obsessional thoughts of suicide or of murdering the children, which may
occur in some depress! ves, may be carried out, and such patients should
always be adnutted to hospital for treatment.

The Course of the Illness. — It tends to fluctuate in severity, but
improves as (he years go by. Sometimes the symptoms stop suddenly
and start again just as suddenly some time Ister.

Differential Diagnosis.—

Depretsion.—^Some depressed patients have obsessions, but usually
single obsessions. Very rarely some female depressives are obsessed by
a short four-lettered word. They are terribly ashamed, intensely
depressed, and usually suicidal.

Early morning waking, diurnal variation of mood, well-marked guilt
and self-reproach, and hypochondriasis suggest the depressive basis of
an obsessional state.

Schizophrenia. — In the author’s experience obsessions rarely occur
at the oiuet of schiaophrenia. If they do occur other indications of
schizophrema can usually be found.

Many obsessional neurotics are very peculiar people, so that if they
suffer from a depression (autonomous dysthjTnia) or a psychogenic
reaction they may present with very strange symptoms. Atypical
illnesses of this Idnd may be mistaken for schizophrenia.

Organic States. — Some post-encephjditic patients have forced
thinUng during oculogyric crises. The features of post-encephalitic
Parkinsonism are usuaUy dearly present. Other organic states are
rarely complicated by obsessions.

Treatment —

Psychoanalysis. — ^There is no dear evidence that obsessional neurotics
are cured by psydinanalysis. All psychoanalysts ^ee that it is a
diihcult illness to treat.

Supportive Psychotherapy and General Measures. — ^Thc therapist and
the patient discuss the symptoms. This often helps the patient because

PSYCHOGENIC REACTIONS 85

his symptoms seem so bizarre to him that he cannot talk about them
with friends and relatives.

The individual must be kept fully oompied. In severe exacerbations
in*patient care is recommended with a full programme of occupation.

Drugs. — Barbiturates, meprobamate, and phenothiazines may be
useful when the patient is very tense. There is a danger of addiction to
barbiturates {see p. no).

Leucoionty . — A modlGed leucotomy is indicated in the patient wth a
good previous personality, with severe obsessions associated with
marked tension, who has made great efforts to carry on mth his life
with the help of supportive psyd»otherapy for several years.

A grossly abnonnal personality, onset in childhood, and atypical
symptoms are contra-indications.

DEPRESSIVE REACTIONS

Reactive unhappiness is a normal event, but some personalities’
particularly the reactive-labile, subdepressive, and cyclothymic types,
easily become depressed and the depression lasts an undue length of
time. Severe prolonged reactive urthappiness is often called ‘reactive
depression’ although it is quite different from a depressive illness
(autonomous dysthymla). The reactive depressive is often angry and
resentful and blames others for his condition, while the patient with a
depressive illness usually blames himself. Delusions or overvalued
ideas of ill health, self-reproach, persecution, and poverty do notoccurin
reactive depression. This disorder is also kno%vn as a ‘neurotic depres-
sion’, but if one applies the criterion of insight, mild depressive illnesses
without delusions can be called neurotic depressions. As a depressive
illness (autonomous dysthymia) can be provoked by psychological
trauma it is not ahvays easy to decide if a mild depression is a depressive
illness or a reactive depression.

HYPOCHONDRIACAL DEVELOPMENTS

These are more likely to occur in anankastic, overpredse, over-
persistent, and asthenic personalities. The patient develops the fear
or the overvalued idea that he has a physical illness. Sometimes the
disorder begins after a transient autonomic disturbance, such as a
burst of extrasj’stoles. In other cases it follows some event which makes
the patient become more observant of his bodily functions. A friend
may die from cardiac infarction and this may make the patient worry
about slight aches and pains in the chest. In other cases the hypo-
chondriasis bepns after extramarital sexual intercourse, when the
patient is frightened that he has been infected with venereal disease.
The fears of disease give rise to anxiety which causes autonomic
symptoms which reinforce the patient’s fears.

86 AN OUTLINP OF PSTCltlATRY

Some hypochondriacal pattenta arc frightened that they may have a
physical illness, while others appear to experience unpleasant sensations
which give rise to hypochondriists. Leonhard has called the first type
ideohj-pochondriacal and the second scnsohypochondriacal. The
sensations which the scnsohypochondriacal patient complains of are
plastic descriptions of pain and abnormal sensations which on the whole
are incomprehensible to the ordinary healthy person, llie treatment
of these patients with psychotherapy is not very easy, as they are
unable to get away from their fears of, or beliefs in, pljysical illne^.

PARANOID REACTIONS AND DEVELOPMENTS

These can also be called detusion>{ike reactions and developments,
because the delusions which occur are understandable results of the
interaction of the personality and the environment. This type of
reaction and development is more likely to occur in paranoid and over-
persistent penonalities and also in patients wHth deformities and
deafness.

Ideas of persecution may develop in a paranoid or overpersistent
personality when subjected to constant bullying by a harsh insensitive
superior. The ideas of persecution naturally die away when the
patient is removed from the stressful rituation. Sensitive personalities
may develop paranoid reactions when their weaknesses sre exposed
by some key experience. For example, a sensitive personality may be
worried about his illegiUmacy and when this fact accidentally becomes
public know ledge, he may develop a paranoid reaction. Some paranoid
and overpersistent personalities have hypomanic traits and tend to
become querulous. They are always fighting for their rights and for
the rights of others. The)' may get themselves involved in law suits,
w hich they carry on interminably. When judgement goes against tliem,
they accuse the judge of being bribed and claim that witnesses have
been suborned.

Morbid jealousy is a common paranoid development, in which the
patient has delusions that the spouse is unfaithful. It can occur in either
sex, but appears to be more common in men, so that it is sometimes
known as the 'Jealous husband’ or the 'Othello syndrome*. Usually
the patient comes from a broken home or a sodal background in which
marital infidelity is not uncommon. Accusations of infidelity are at
first intermittent, but later they become almost continuous, although
they fluctuate in intensity. The wife may be beaten or cajoled into a
false confession. These patients may be extreme^ viohmt and can
Severely injure or even murder thar wives. Often the patient givTS a
detailed account of an episode of suspicious behaviour on the part of
the wife an’d claims that he knew after this event that his wife was

PSYCHOGENIC REACTIONS 87

unfaithful to him. For example, a patient said that while he was lying
in bed during the day he saw hfe wife and son-in-law misbehaving in
a mirror which hung on the tvall of the corridor opposite his bedroom.
He could not explain why he did not get out of bed and tax his wife
with her immoral behaviour. Accounts of this kind are always produced
long after the patient has begun to accuse his wife of infidelity and are
of the nature of retrospective falsifications. These patients often produce
ridiculous evidence that their wives are unfaithful. They claim that
there are seminal stains on the wife’s undertvear, that the vagina is
moister than usual, and that she looks debauched.

Erotomania is a rare psychogenic reaction or personality develop-
ment in which the patient, usually a women, believes that someone of
the opposite sex is in love with her although the alleged lover has given
no substantial indication of his lo\'e. The patient knows that she is
loved because of the way in which the lover looks at her or the way he
shakes her hand and so on. Often the patient has only seen the lover at
a distance and has not spoken to him. Erotomania can be a transient
disorder in adolescence or a personality det'elopment in middle life, but
schizophrenia may begin as erotomania and clear schizophrenic
symptoms may only become obvious after many months.

CHAPTER VII

PSyaiOSOMATIC disorders

DEFINITIONS AND GENERAL PRINCIPLES

Definition. — ^The term ‘psychosomatic’ has been used rather
loosely for many years. It has been used so inconsistently that the
official American classihcatioit of psychiatric disorders does not use it,
but uses the term ‘psychophysiolopcal* instead. The word ‘psycho-
somatic’ has been used for any somatic symptom which is partly or
^\holly the result of a psycholo^ca) conflict. This is confusing because
such different conditions as hysterical hemiplegia and peptic ulcer
could be classified together as psychosomatic disorders. The term
‘psychosomatic’ lias also been applied to the approach to illness in
which the physician takes into account the social and physiological
factors as well as the physical factors. This is the correct practice of
medicine and does not need a special designation. The author is of the
opinion that the word ‘psychosomatic* should be restricted to that
group of disorders which are not neuroses or psychoses, but in which
psychological factors appear to play an important part. This gives the
follom'ng definition:—

A psychosomatic illness is one in which psychological factors appear
to play an important part in the production of a disorder in the function
or the structure of the body. If the disorder is one of function it is not
normally associated with emotion and it is not being presented uncon-
sciously for the sake of some advantage.

Freudian Views. — Freud distinguished between neurotic symptoms
which were symbolic of a conflict, i.e., conversion symptoms, and those
neurotic symptoms due to a neurotic misuse of a given function. His
followers have called this second sarte^ ‘organ neurotic’. Fcnichcl
(1945) suggested that there were three ways in which organ neurotic
symptoms might arise: —

1. Affect EquivaletUs. — The phyucal accompaniments of emotion
occur without the patient being fuUy aware of the emotion.

2. Chronic Frustration producing Chemical and Physical Changes . —
Chronic anxie^ in someone unable to escape from unpleasant situations
may produce changes in the endocrine and nervous systems.

3. Unconscious Attitudes producing Pl^’sieal Symptom. — For example,
a person who for unconscious reasons continually clears his throat may
develop a mild chronic pharyngitis.

PSYCHOSOMATIC DISORDERS

Despite the non-symboHc nature of organ neurotic symptoms many
psychoanalysts give ‘dynamic’ explanations of psychosomatic diseases.
Thus Fenichcl suggested that in the peptic ulcer patient there are
chronically frustrated oral receptive attitudes, which are repressed,
giving an unconscious hunger for love, often with a reaction formation.
The subject behaves physiologically like a permanently hungry person
so that Ws gastric secretion becomes excessive and an ulcer occurs.

Alexander’s Views. —

The Two Basic Attitudes. — According to Alexander (1952) there are
two basic attitudes, the inhibition of which may cause physical
symptoms.

The response of an organism to a threat may be: —

1. Fight or flight, both of which arc associated with the same
emotional attitude and activity of the sympathetic nervous system.

2. Withdrawal from activity (‘playing possum’) which is associated
tvith a different emotional attitude and activity of the parasympathetic
nervous system.

InhSntion of Flight or Fight jf/Zi/ade.— The human being may be
obliged to inhibit his tendencies to fight or flee from the situation. This
causes chronic over-artivity of the sympathetic nervous system, which
may result in essential hypertension, diabetes mellitus, rheumatoid
arthritis, or thyrotoxicosis.

Inhibition of the Withdrawal Reaction. — ^When this attitude is non-
adaptlve it may be inhibited, but the over-activity of the parasympathetic
nervous system continues. This may cause nervous indigestion, nervous
diarrhoea, cardiospasm, colitis, constipation, peptic ulcer, ulcerative
colitis, or asthma.

Further Developments. — Although the initial over-activity is mainly
sympathetic or parasympathetic, readjustment may occur later and there
may even be an overcompensation.

Criticism, — Alexander takes over Cannon’s concept of antagonism
between the two different parts of the autonomic ner\’ous system, but
it is generally held that the autonomic system works as a whole, so that
the relation between the sympathetic and parasympathetic systems is
complex and not a simple antagonism.

Apart from this, the same person can have two or more psychosomatic
disorders allegedly due to over-acUvity of both parts of the autonomic
nervous system. Alexander indudes many illnesses as psychosomatic,
in which the probability that psychofogfcal factors play a part is
doubtful, to say the least.

Personality Theories. — ^Various authors have described peptic
ulcer personalities, asthmatic personalities, and so oru It is, however,
difficult to find clear differences between different personalities which

90 AK OUTtrNB OF MYCHIATRY

have been described as spcdfic for psychosomatic disorders. Another
difficulty is that the same patient may suffer from two or more psycho-
somatic disorders.

ConOlct Theories.— “Some worke» claim that psychosomatic
disorden are the result of specific conflicts associated with fixation
points in libidinal dwelopment (tee p. 25). An example of such a
thcoiy is the view that the peptic ulcer patient has intense oral-
dependent desires, or, in other words, he has unresolved conflicts at
the early oral stage of infantile sexual dc^'cIopmcnt. This gives rise to
a craving for orzl satisfacdort which if it is denied leads to peptic
ulceration. The patient may, however, deal with this craving in
different wajs. Thus Rosenbaum has described three groups of ulcer
patients all of whom had excessive oral-dependent needs. These were: —

1. Pseudo-independent personalities, who overcompensated for
their excessive oral-dependent needs by becoming ambitious and
successful.

2. Passive-dependent personalities who were quiet and shy.

3. Acting-out personalities, who expressed their strong ond cravings
in their behariour. These patients drank heavily, were compulsive
gamblers, were often oiminats, and were unable to hold down a regular
job. Rosenbaum compared these patients will) unwanted sucklings
whose oral needs are insatiable.

These descriptions of different types of ulcer patients look neat and
tidy, but all we are being told is that peptic ulcers occur in driving-
successful, shy-introverted, and antisocial people. ^Yith not too much
effort it should be possible to fit a random sample of the population into
these three groups. Another criticism is the sequence of ev’ents. It is
virtually impossible to decide if the oral-dependent desires are primary
or secondary. The peptic ulcer patient is naturally worried about the
effects of eating, so that it is likely that he trill talk about oral topics in
psychotherapy much more than a normal person would.

VARIETIES OF PSYCIlOSOhiATIC DISORDER
The following illnesses have been claimed as psychosomatic: —
t. Retpiralory Disorders . —
a. Bronchial asthma.

A. Vasomotor rhinitis.
c. Hay fever.

2. Gastro-intestinal Disorders . —

a. Peptic ulcer.

b. The irritable colon syndrome,
e. Ulcerative colitis.

3. Endocrine Disorders . —

a. Hyperthyroidism (Grave’s disease).
h. Diabetes mcllitus.

c. Menstrual disorders.

d. Obesity.

4. Cardiovascular Disorders . —

a. Essential hypertension.

b. Coronary artery disease.

c. Paroxysmal tachycardia.

5. Rheumatoid Arthritis . —

6 . Skin Disorders . —

a. Psoriasis.

b. Urticaria.

9 *

RESPIRATORY DISORDERS

Bronchial Asthma. — ^The basic disorder in bronchial asthma Is the
narrowing of the lumen of the smaller bronchi as a result of the con-
traction of the circular muscle of the bronchus and/or swelling of the
bronchial mucosa. Three factors play a part in bronchial asthma: —

1. Allergy.

2. Infection.

3. Emotional disturbance.

In any given case one, two, or all three of these factors may play a
part. There appears to be an inherited predisposition to asthma,
because there is an excess of bronchial asthma and infantile ecaema in
the families of asthmatics. Asthma begins in childhood and often
produces a vicious circle of anxiety. The mother worries about the
child and transmits her anxiety to him and this may cause further
asthmatic attacks. What would other^vise have been a normal mother-
child relationship is distorted by the natural anxiety produced by the
illness. Another factor is that the attacks of asthma give the child a
special status in the family and he may use his illness to gain attention
or to get his own way.

There is very clear evidence that asthma can be caused by emotTonal
disturbance or by suggestion. Thus Herxbeimer found that when
asthmatics were placed in situations in which they had previously been
exposed to allergens they had attacks of asthma, although they were not
exposed to an allergen. The situation became a conditioned stimulus
for an asthmatic attack. Many different investigators have shown that
allergic reactions can be accentuated by stress. The relation between
allergy and emotion in asthma is very well illustrated by the story about
the famous physician Trousseau, who suffered from asthma and was
allergic to oats. Normally when he went into his stables he had a mild
wheezing, but not a severe attack of asthma. One day he went into his

gz AN OUTLINE OP PSYCHIATRY

stables and dbcovercd that his coadunan had been s^vindI^ng him. He
became very angry and had the worst attack of asthma that he had ever
had in his life.

Various types of personality have been described as typical of
patients with asthma, but these claims have not been substantiated.
Objective studies with the Maudsicy PersoiuJity Inventory and the
Cornell Medical Inventory by Rees have 8ho\vn that the asthmatic
tends to have a score midway between normals and neurotics. Rees
found a higher prevalence of psychological factors in asthmatics who
developed asthma for the first rime after the age of 45. One pycho*
analytic view is that there is an excessive unresolved dependence on the
mother. This is unconscious, but any threat of separation from the
mother or mother-substitute causes an attack of asthma, which is really
a suppressed cry for the mother. This theory is not very convindng
because attacks of asthma may occur in very young children and it is
difiicult to see why such patients should suppress a cry for the mother.

Vasomotor RMnItls. — ^This consists in attacks of rhinorrhoea,
with sneeaiflg and difficulty in breathing through the nose. The
immediate cause of the symptoms is an exetssive secretion of the nasal
mucosa with swelling and increased v-ascularity. Allergy, infection, and
emotional disturbances may all play a part in producing attacks.

Hay Fever.— This is an allergic condition, in which the nasal
mucosa is allergic to pollen. Ps)'chological factors do not play an
important part in this typical allergic illness.

GASTRO-INTESTINAL DISORDERS

Peptic Ulcer.— This tenn will be used for ulcers aifecting the
prepyloric portion of the stomach and the duodenum. These ulcers
are quite different from gastric ulcers affecting the body of the stomach,
and in the following discussion gastric uJeers will not be considered.

Experimental BaJenee, — It has been knowm for many )ear3 that
damage to the hypothalamus produces gastric and duodenal ulceration.
Lesions of the brain following cerebral thrombosis in human beings
have been known to rause gastric ulceration. In unanaeslhetixed
monkeys stimulation of the anterior hypothalamus gives rise to a vagus-
mediated secretion of hydrochloric add in the stomach, which reaches
its peak in 1 hour, while stimulation of the posterior hypothalamus
causes secretion of hydrochloric add whidi peaks in 3 hours and is
mediated by the pituitary and the adrenal cortex.

One group of investigators took xo monkeys and placed indwelling
electrodes in the hypothalamus, which was then stimulated for
15 minutes every 4 hours for periods of 1-3 months. Four of the animals
developed ulcers at the pyloric end of the stomach or in the duodenum.

PSYCHOSOMATIC DISORDERS 93

It has also been sho%vn that situations which cause chronic anxiety in
monkeys can cause peptic ulcers. One group of American research
workers carried out an ingenious experiment using 2 monkejs. One
monkey had to solve a problem and move a lever indicating the solution.
If he gave the wrong response he received an electric shocL The
second monkey had no problems to solve, but always received an
electric shock when the first or executive monkey made a mistake and
received a shoc^. After a few days the executive monkey developed a
peptic ulcer, while the second or passive monkey did not.

Personality Types . — ^Various types of personality have been alleged
to be associated with duodenal ulceratioiL At one time it was firmly
held that peptic ulcers were more common in anxious, tense, hard-
working obsessional personalities, but this is not true. Gosling found a
high prevalence of peptic ulcers in hospitalixcd neurotics, especially in
those with depression and those who were both asthmatics and
alcoholics.

Conflict Theories . — The theory that peptic ulcer is the result of
frustrated oral receptive longings has already been discussed {see
p. 90).

Response to Treatment.— Qittn wbetr intractable duodenal ulcers
are treated with gastrectomy some new nervous symptoms appear.
Browning and Houseworth compared the results of surgical and
medical treatment in two groups of patients with intractable ulcer symp-
toms. In the surgical cases 43 per cent still had ulcer symptoms after
operation, but the incidence of other psychosomatic symptoms increased
from 13 per cent before operation to 37 per cent ^ter operation and
neurotic symptoms increased from 50 per cent to 100 per cent. In
another study the results of operations for intractable ulcer symptoms
were compared with the results of operations for complications, such
33 perforation, haemorrhage, and obstruction due to duodenal ulcera-
tion. Ninety per cent of the patients with complications made a
satisfactory recovery, while only ^ per cent of patients with intractable
ulcer symtoms did so. Other interesting findings are that the suicide
rate is higher after gastrectomy for peptic ulcer and that alcohol
addiction is also more common.

The Irritable Colon Syndrome. — ^This has also been called the
spastic colon and mucous colitis. It is characterized by alternating
diarrhoea and constipation, abdominal pain, flatulence, and at times
excessive quantities of mucous in the stoob. It seems that patients
with this complaint have colons which react more readily to para-
sj'mpathetic stimulation than the normal. It has been claimed that
patients with thb syndrome have rigid obsessional personalities, are
often depressed, and arc more likely to have severe depressive illnesses.

94 AN OUTLINE OF PSYCHIATRY

Ulcerative Colitis. — This has been claimed to be a psjchosamatlc
disorder, but this view is not accepted by many gastro-cntcrologists.
The popular alternative theories of aetiology are allergy and auto-
immune disease.

Personality Types . — It has been claimed that a passive dependent
personai'ty is ch^cteristic of ulcerative colitis patients, but the
itself makes the patient passive and dependent.

Conflict Theories . — Engel claims that the relationship of the patient
with the mother is of primary importance. The mother is dominating
and the patient feels obliged to behave in a «-ay which she consciously
or unconsciously demands. The onset or the exacerbation of ulcerative
colitis occurs when the key relationship with the mother or some
symbolic representation of this relationship is threatened, llie patient
feels helpless and the situation may be too much for him. Typical
situations are: —

I. Being asked to do something which he feels incompetent to carry
out.

a. Disapproval or threat of disapproval from some key figure or
substitute.

3. Real, threatened, or feared separation from the key figure.

Engel recognizes that similar conflicts can be found in patients who
do not suffer from ulceratit e colitis, so that there must be some physio-
logical mechanism which determines the ulcerative colitis.

ENDOCRTNE DISORDERS

Endocrine Psychosomatic Relationships. — In the past there has
been a tendency to look upon honnones as the primary cause of
emotional and behavioural patterns. In fact hormones release,
potentiate, or inhibit patterns which arc Wd do\vn in the nervous
system and are, therefore, only partial causes of patterns of behaviour.
The endocrine glands are directly or indirectly under the control of the
nemius system. Thus there arc areas in the hypothalamus which
directly or indirectly control the release of pituitary hormones. The
final result of the activity of these centres is fed faa^ to them, so that
their activity is controlled. The hormones which are produced by the
peripheral endocrine glands may in turn have an effect on other
hypothalamic centres producing c^ngein behaviour patterns. 'Ihos the
gonadotrophic hormone of the pituitary acts on the ovaries which
produce oestrogen which has an ^ect on the female genitalia, but this
hormone also affects the hypotbalamic centres making the female
animal sexually receptive.

Hyperthyroidism (Graves* Disease). — ^There is no doubt that
psychoJogici factors play a part in this illness.

PSYCHOSOMATIC DISORDERS

95

Psychological Trauma. — In some ca^ the illness appears to follow
a severe emotional trauma. For example, a farmer came home to find
his house on fire and despite all his efforts his wife and children were
burnt to death before his eyes. Shortly after this he developed severe
thyrotoxicosis. In other cases bereavement or prolonged emotional
tension appears to have precipitated the illness.

Psychological ConjUcis. — Psychoanalysts have suggested that the
hyperthyroid woman has an unusual emotional attachment and
dependence on a parent usually the mother during childhood and any
threat to this relationship is intolerable. Often as a child the patient
has been insecure, because of economic difficulties, divorce, death of a
parent, or the presence of a large number of siblings. The patient then
tries to identify with the parent on whom she feels dependent and fails
to do so. This leads her to premature self-sufficiency and a tendency to
dominate others by giving attention and affection. If this defence
breaks dowm thyTotoxicosis occurs.

Any explanation of the cause of thyrotoxicosis must account for the
fact that this illness is much more common in ^^’omen. As in other
psychosomatic disorders it seems necessary to postulate an inborn
mechamsm which is the essential cause of the illness.

Diabetes Mellltus, — ^This has been regarded as a psychosomatic
disorder, but the accepted view is that it is an acquired or inherited
organic disorder. Cases have been reported in which the onset of the
disease was preceded by severe emotional stress, but these may be
chance findings. It^as, however, been shown that stressful situations
in the established diabetic may produce marked changes in the insulin
requirements. Situations which cause feelings of frustration, loneliness,
or dejection are often followed by glycosuria and an increase in the
iiuulin requirements, while satisfactory solution of psychological
confficts which leads to greater security may lead to a decrease in
insulin requirements and hypoglycaemia.

Menstrual Disorders. —

Amenorrhoea. — ^This may result from psychological trauma. For
example, 73 women of a series of 732, who had been sexually assaulted,
had amenorrhoea which ^V3S not due to pregnancy. Out of a total of
450 women, 234 who were interned in the Hong Kong Japanese
internment camp developed amenorrhoea follo\ving internment,
although the diet w-as adequate at the time. Some depressed patients
have amenorrhoea and a few chronic female schizophrenics do not
menstruate.

Menorrhagia. — ^Thls can occur in women under stress and some-
times occurs in depressive illnesses.

Dysmenorrhoea. — It has been claimed that this is due to a faulty
attitude towards sex and that the woman with dysmenorrhoea is

96 AN OUTtlNE OF PSYCHIATRY

rejecting the female role. Dysmenorrhoea is very common, and Kessel
and Coppen in an unseleclcd sample of women of menstrual age found
that 12 per cent had severe pain and 33 per cent had moderate pain at
the onset of a period. Dysmenorrhoea was not affected by marriage,
but declined with parity. The same investigators administered the
Maudsley Personality Inventory to a sample of 500 women and found
that dysmenorrhoea was not associated with high scores on ncuroticism
or extraversion, which would be expected if the disorder was hysterical.
On the other hand, they found that women with premenstrual tension
had high neurotidsm scores. The finding that dysmenorrhoea does not
appear to be a neurotic condition is confirmed by an investigation
of 800 female students, in which it was found that there was no
greater Incidence of psychological disorders in those students with
dysmenorrhoea.

Premmstnal Tension . — In this condition physical and mental
symptoms occur in the second half of the menstrual cycle. The patient
becomes anxious, tense, and irritable and there may be depression,
bloated feelings, fatigue, nausea, painful swelling of the breasts, head-
aches, dizziness, and palpiutions. Less often there is increased
sexual desire, excessive thirst, increased appetite, and hypersomnia.
The symptoms begin 7-14 days before the period and pass off when
menstruation begins. It has been claimed ^t this syndrome is the
result of faulty (uteinization, so that the action of the oeatrogenproduced
by the ovary is not antagonized. The physical symptoms may be
relieved by giving diuretics, but complete relief is produced by sub-
stances tvith progestin activity, such as dimethisterone and nore*
thisterone.

Obesity. — In the past this has been regarded as an endocrine
disorder, but there is no evidence that it is tlie result of hormone
imbalance. It is well knonm that obesity occurs in some patients with
hypothalmic lesions. Recent work in animals has shmvn that there is a
satiety centre in the medial hypothalmic region and a feeding centre in
the medial hypothalamic region and a feeding centre in the lateral
hypothalamus. It used to be held that overeating was the cause of
obesity, but tUs does not explain uhy the same intake of food will
produce obesity in one individual and not in another. Nor does it
explain why some patients overeat. It seems that constitutional factors
play a part. In some cases, however, emotional factors are important.
In one series of obese patients it was found that neurotic traits and
symptoms were much more common than in the normal population.
Many obese pati’ents feel contented when overweight and became
miserable and depressed when they are on a diet and losing weight. No
special kind of personality or psychological conflict has been found

PSYCHOSOMATIC DISORDERS

97

among obese patients. Two interesting patterns of overeating are
found in a few obese patients under stress. These are the night-eating
and the binge-eating syndrome. The first occurs in about lO per cent
of obese persons and is more often found in women. There is anorexia
in the morning, hyperphagia in the evening and insomnia. The binge-
eating syndrome occurs in less than 5 per cent of obese subjects and
is characterized by the sudden impulsive consumption of large
quantities of food in a very short space of time, followed by agitation
and self-condemnation. These binges tend to occur after a frustrating
experience, possibly within minutes of the stress.

CARDIOVASCULAR DISORDERS

Essential Hypertension. — Tn Britain many physicians do not
accept that this is a psychosomatic disorder. In a recent retiew of the
problem of hypertension, Pickering, who has made a life-time study of
the illness, paid no attention to the possible psychological causation of
hypertension.

It has been suggested that the patient with essential hypertension is
someone who has difhculties in controlling his feelings of anger, so
that his chronic iU-controlled aggression gives rise to an increase in
blood-pressure. Another theory is that the hypertensive is predisposed
to react excessively to painful stresses with an overactivity of the
autonomic nervous system. This causes a rise in the blood-pressure
and after prolonged neurogenic hypertension physical changes occur
in the heart and blood-vessels.

Coronary Artery Disease.— Various groups of investigators have
claimed that str«s will disturb the coronary artery circulation. The
most popular theory of the aetiology of coronary artery disease is that
it is due to hypercholesterinaemia caused by diet and constitutional
predisposition.

Persmality Theories . — A typical coronary personality has been
described as a restless, ambitious, overscrupulous, compulsive man
who drives himself too hard and is often overburdened with the care
and responsibility of office. The evidence of a personality abnormality
in this illness is conflicting. Thus one investigator compared the
personalities of patients with hypertension, rheumatic heart disease,
coronary occlusion, and non-car^ac infectious diseases and he could
find no statistically significant differences between these groups.

Epidemiological Studies . — A group of Belgian and Dutch doctors
investigated the incidence of hypertension and coronary thrombosis in
Trappist and Benedictine monks. The Trappists lire a quiet life of
meditation, while the Benedictines lead an active life which is not too
dissimilar from that of the average West European. There was no

7

98 AN OUTLINE OF PSTCJllATRY

difference in tJjc incidence of coronary thrombosis or hypertension in
tile tno groups of monks, but the incidence of these illnesses was
significantly lower in both groups compared with the general popula-
tion. It was suggested that this was the result of psychosodal factors
rather than diet.

Most epidemiological work suggests that restricted physical activity
plays a part in the causation of coronary thrombosis. Thus Morris
showed that sedentary workers had coronary thrombosis more often
and more seriously than physically energetic workers. Some other
findings contradict this to a degree. For example, it was found that the
highest incidence of coronary thrombosis was in Social Class 11 and
that the incidence in Sodal Class V was greater than in Soda! Qasses
III and IV. One interesting finding by Morris was that the Incidence
of coronary disease among general practitioners W'as twice that among
medical specialists. On the whole, epidemiological studies tend to
discount the role of personality and psychological trauma in coronary
thrombosis and to incriminate physical inactivity, diet, smoking, and
certain occupations.

Paroxysmal Tachycardia.— In an unselected series of patients
with paroxysmal tachycardia, Fish found that the majority were
suffering from a reactive anxiety state or a depressiv*e illness. Stolcvis
trained a patient to think himself into an attack of paroxysmal tachy-
cardia in order to prevent his deportation from Holland to a German
concentration camp. There is little doubt that this condition has a
neurophysiological basis, but nevertheless psychological factors appear
to bring the patients to the cardiologists.

RHEUMATOID ARTHRITIS

Aetiology . — This illness primarily affects the joints, particularly the
small joints of the hands and feet, but it may affect other parts of the
body. It is associated with a rise in temperature, tachycardia, and
general malaise, so that it has all the appearances of an infective disease.
No causative organism has ever been isolated and the most popular
aetiological theory is that it is an auto-immune disease. As with other
illness where the aetiology is obscure rheumatoid arthritis has been
supposed to be a psychosomatic disease. As the illness is often chronic
and severely incapacitating it naturally leads to psychological dis-
turbances.

Personality Theorits . — It has been suggested that the typical
persomlity in rheumatoid arthritis has profound inunaturity, marked
feelings of inadequacy, difficulty in expressing feelings, and often
severe anxiety. The psycholopcal conflicts resulting from the
personality difficulties are suj^wsed to lead to ovcractivity of the

PSYCHOSOMATIC DISORDERS 99

autonomic nen'ous system, nhich in some \vzy causes the joint disorders,
A more ingenious theory is that the autonomic activity causes circulatory
disturbances, which give rise to tissue damage, which in turn gives rise
to the antigens which produce auto-immune disease. To say the least
this is a litde far fetched.

SKIN DISORDERS

The fact that psycholo^cal factors play a part in skin diseases has
been recognized by dermatologists for years and phenobarbitone has
often been prescribed for the skin patient.

Psoriasis. — It is well known that this condition may be provoked
by psychological trauma, but it may also follow infectious illnesses and
skin trauma. It is probably the result of an inherited predisposition of
the skin to react in a special way.

Urticaria. — It has been claimed that personality disorder is
common in chronic urticaria, while emotional stress is often found in
acute urticaria. The relation between urticaria and emotional stress is
well shown in the case of the patient who aln-ays had an attack of
urticaria when be was annoyed He was admitted to hospital for
investigation and the nursing staff were persuaded by the investigators
to falsely accuse the patient of some minor infringement of the hospital
rules. This made him angry and within a few minutes he developed
an urticarial rash. Perhaps the most Interesting patient is the woman
who was dining with her lover and earing lobster when her husband
surprised her and she immediately developed generalized urticaria.
Previously she had not been allergic to lobster, but after this episode
she always had urticaria whenever she ate it.

SUMMARY

Since many people with the same psychological difficulties which
are allegedly specific causes of psychosomatic disorders suffer from
neuroses and may even pass for normal, it is difficult to regard the
psychological factors in psychosomatic disorders as more than con-
tributory, There must be some, as yet undiscovered, disorder of the
nervous system in each variety of psychiKomatic disorder.

100

CHAPTER VIII
DRUG DEPENDENCE

Drug Dependence. — In *958 the Expert Committee of the World
Health Organiration distinguished betneen habituation and addiction,
in an attempt to differentiate psychological from phjxical dependence.
In a more recent report (1964) this committee has used the term ‘drug
dependence* for both habituation and addiction. This is more logical
because one patient may have a psychological dependence on a given
drug, while another has a physical dependence. The W.H.O. Expert
Committee deRnes drug dependence as a condition arising from
repeated administration of a drug on a periodic or continuous basts.
Its characteristics will vary with the agent involved and this must be
made clear by designating the particular type of drug dependence in
each apecific case — for example, drug dependence of morphine type,
of cocaine type, of cannabis t^e, of barbiturate type, of arnphetamiae
type, etc.

AleohoUsm. — This term is used rather loosely to designate heavy
drinkers of all kinds. It is better to use the following terms: —

1. Symptomatic Habitual Drinkers. — ^They can stop when they want
to.

2. Alcohol Addicts. — They have ‘loss of control’, i.e., once they start
drinking they cannot stop until they are too drunk or too ill to drink
more.

3. Akoholus. — They shoiv mental and pfaj-sical changes due to
alcohol.

ALCOHOL ADDICTION

Aetiology. —

Soa'al Factors. — Some people become alcoholics because they live in
an environment where heavy drinking u the rule, for example, business
men, publicans, and barmen. Anything which leads to the rapid
drinking of hard liquor will lead to addiction, for example, licensing
laws and poor drinking conditions.

PsycMairic Jl/nmej. — On the whole, the major psychoses are not
associated with alcohol addiction in Britain. Chronic anxiety states
may lead to drinking when the patient finds that alcohol calms him
dotvn.

DRUG DEPENDENCE

101

PertonalUy Abnormalities. — Some psychopathic personalities are
inter alia alcohol addicts. Gloomy, anxious, inadequate people may
drink for relief and become addicts. Periodic drinkers are psycho-
pathic personalities with periodic crises in which they drink to seek
oblivion.

Biochemical Disorders. — It is difficult to find a psychological explana-
tion of why only a certrin number of heavy drinkers become addicts.
Many investigators have postulated a biochemical basis for alcohol
addiction, but this has not been demonstrated so far.

Psychoanalytic Theory. — ^The alcohol addict has an oral narcissistic
personality. The child is frustrated at the oral stage of development.
Oral anxieties are carried over to the Oedipal stage and the vulva is
regarded as a means of castration. The child is disappointed by his
mother and regresses from object love to identification with the mother.
He thus needs a sexual partner with a penis, because of his identification
and his castration anxiety. However, this process is not complete and
the subject is capable of object love and to some extent becomes
identified with his father or the masculine aspects of his mother. He
becomes a latent homosexual. Drinking satisfies his oral needs, and as
this leads him into a predominantly male environment his latent
homosexuality allows him to fit into and enjoy this environment.

The Development of Alcohol Addiction (Jellinek)*. —

The Pre-alcokolie Phase. — ^The subject drinks for the relief of
symptoms, at first occasionally and later continuously.

The Prodromal Phofe.— This is marked by the onset of ‘blackouts’ in
which after a moderate intake of alcohol the patient behaves normally
but does not remember what he has done (anterograde amnesia). This
phase progresses with surreptitious drinking, arid drinking, guilt
feelings about drink, and aN'oidance of all references to drink. The
frequency of the ‘blackouts’ increases.

The Crucial Phase. — ^This begins with ‘loss of control’. The phase
progresses with regular drinking and rationalization of drinking
behariour.

The Chronic Phase. — ^This is ushered in by the onset of ‘benders’,
i.e., the patient drinks steadily day and night for several days, neglecting
everything to do so. The phase progresses with ethical deterioration,
the drinking of toilet products (surgical spirit and bay rum), the loss
of tolerance to alcohol, obsessive drinking, and tremors. Finally,
all defences fall; he adnuts he is an alcoholic, but he goes on
drinking.

Treatment. — ^This is mrinly by psychotherapy, but some phj'sical
methods may be helpful adjuncts,

* See W.H.O. Technics! Repwts, Series 48 (1952).

102

AN OUTLINE OF PSTClirATRY

Psychotherapy: Tia Basic Roles.—

t. The patient must agree that he is an alcohol addict and that he
must not drink alcohol for the rest of his life.

2. No pledges or promises should fac extracted from the patient.

3. The patient must be frank with the therapist and contact him as
soon as possible in the event of a relapse.

4. The patient must be treated as ao adult by the therapist and the
relatives. He must make his own decmoos and be responsible for his
actions.

5. Threats of ph3'sical, mental, or soda! ruin are worse than useless
and may produce an * I don’t care if I do die* attitude.

Points about Psychotherapy. — ^The problem is to help the patient find
something worth while which will fill up the gap in his life left by giving
up alcohol. Religious activities or some kind of help for others may
fill this gap. Alcoholics Anonymous (A.A.) is an organization of ex-
alcoholics who help alcoholics to give up drinking. This is really a variety
of group therapy with the additional advantage that the patient is able
to live a life wth some meaning, i.e., he helps himself by helping others.

Physical Treatment.—

Disulfiram (Antabuse, Cronehrf).— This substance inhibits the
enzyme responsible for the breakdown of acetaldehyde, an intermediate
metabolite in the utilization of alcohol. If the patient drinks while
taking the drug he is upset by the acetaldehyde, which causes Bushing,
tachycardia, dyspnoea, nausea, and vomiting. A dose of 0*5 g. of the
drug is ^ven twice daily for a week, and then 0*5 g. is taken daily.
Tov^ards the end of the first week a test dose of 2-4 fi. oz. of spirits in
6-joB.oz.oiw2teris taken. This produces a reaction so that the patient
knows what to expect. This drug is a useful prop in a reasonable
patient who Is likely to have drink forced upon him. It should not be
given to patients wth severe chest, heart, or liver disease.

Citrated calcium carbimide (abstem) has been introduced as a milder
substitute for disulfiram. It produces no toxic reactions or side-effects.
Sensitivity to alcohol appears within a few hours, but the reaction to a
test dose of alcohol is usually much milder than with disulfiram.

Aversion Therapy. — Four fi. 02. of spirits are given with apomorphine
gr.-^ intramuscularly every 2 hours for 3 days. Injections of
vitamin B complex are given during this time and the patient can drink
as much as he likes but is given no food. Apomorphine is a powerful
emetic and the aim of the treatment is to make the patient vomit at the
s/gbf e>f aicohcA. Un/ortonafely, rias avemoa only lasts a Sevr months
and the treatment has to be repeated frequently.

Prognosis. — ^The best results are obtrined in those patients who
have become alcohol addicts due to social pressures. On the whole, the
prognosis is not good.

DRUG DEPENDENCE IO3

PSYCHOLOGICAL DISORDERS ASSOCIATED WITH
ALCOHOL

Pathological Intozicatioti. — After taking a small quantity of
alcohol some indiriduals develop a mild clouding of consciousness and
very violent behaviour. The normal signs of drunkenness arc absent.
On recovery there is usually no memory for the episode. Many of these
patients have abnormal RE.G. records. The illness is an organic
twilight state produced in a susceptible subject by excessive fluid intake
and ^cohol.

Delirium Tremens, —

Aetiology . — Delirium tremens develops after many years of misuse
of alcohol, so that it usually occurs in the fifth and sixth decades.
Infection or injury may initiate the illness. Abstinence from alcohol
is probably the most important causative factor, so that the disorder
can be regarded as a withdrawal phenomenon.

The Prodromal Period , — Often there are prodromal symptoms for a
few days or a week before the ortset. The patient is anxious, tremulous,
and restless, with hypersensitivity to noise and light. Gastro-intestinal
complaints are common. Isolated visual hallucinations occur, especially
in the dark and when the patient ts alone. The symptoms increase in
severity until disorientation and delirium are produced. Epileptic
fits often occur in the prodromal period and may mark the onset of the
delirium.

The Dstoiam.—The general appearance is characteristic. The face is
red, there is marked s^veatlng, and a severe tremor afTecting the hands,
the speech, and the upper part of the body. Visual hallucinations are
outstanding. Small animals, such as beetles, mice, rats, squirrels, and
snakes, are seen, usually accompanied by severe anxiety or intense terror.
Occasionally Lilliputian hallucinations occur, associated mth marked
pleasure. Scenes and pictures are sometimes hallucinated. Halludna-
tions can be suggested and the patient may be persuaded to read from a
plain piece of paper. Hallucinatory voices arc rare, but noises, isolated
words, and music may be heard. Hallucinations of touch, muscle
senses, and equilibrium are very common.

Consciousness is changed in a dream-like way. Disorientation for
time and place is complete, but there is no disorientation for person.
Attention can be obtained for short periods, espedally if the examiner
speaks loudly, slowly, and clearly. In these dreumstances the patient
win answer questions and accept reassurance.

There is marked restlessness with pressure of aairity. Sometimes
the patient carries out the actions of his trade (occupational delirium).
The mood swings between euphoria and anxiety.

There is absolute insomnia and the illness often ends with a so-<alled

104 an outline of psychiatry

'critical sleep* lasting 24-48 hours, at the end of which the patient wakes
recovered or with a Korsakoff state.

Course and Prognosis . — Usually It lasts from 2 to 6 days, but abortive
cases lasting 1-2 days occur. Mortality varies from i to lo per cent in
different series and depends on age and the presence of complicating
illnesses and injuries.

TVefl/ment.— This consists of sedation with phenothiazincs, but
paraldehyde may be used if necessary'. Antibiotics are given for
complicating illnesses. It has been claimed that large doses of vitamin B
complex (parcntro\ itc)* are curative, but this is not certain.

Alcoholic Ilallacinosls, — ^This occurs in hea\y drinken. There is
a sudden onset of phonemes in a state of clear consciousness, or a mild,
transient, delirious state lasting a day or so ushers in the hallucinosis,
which continues in clear consciousness. The voices seem to come from
above the patient’s head; they talk about him in the third person, abuse
him, and call him a homosexual. Because of the voices the patient
believes that he is being persecuted.

Illusions and delusional misinterpretations of sensory' stimuli occur
at night, and occasionally ttsual hdludnatlons, so that a mixture of
delirium tremens and alcoholic hallucinosis is sometimes present.

The hallucinosis lasts longer than in delirium tremens, but half the
patients recover within a month. Patients who do not recover within
six months remain chronic and have intellectual impairmenL

Treatment is the same os that recommended for delirium tremens.

The Alcoholic Korsakoff State.— Korsakoff described a psychosis
characterized by failure of immediate memory and associated with

* This is a ndxture of vitamins for pamiicnl use marketed by \^tainins Ltd.
of London. It is presented as four different preparations in twin ampoules.
These are (a) High potency intravenous; (6) High potency intramuscular,
(r) Maintenance intra\enoua; (J} Alsintenancr intramuscular. The sitamio
content of these preparations is as follows!—

(u)

(«

(c)

(<0

Aneurin HCl

250 mg.

ajo mg.

iQomg.

ICO mg.

Micotinamide

160 rng.

160 mg.

160 mg.

160 mg.

Riboflavine

4 mg.

4 mg.

4 mg.

4 mg.

Pyridoxine

50 mg.

50 mg

scrag.

scrag.

Dextrose

t g.

—

—

—

Ascorbic acid

500 mg.

500 mg.

soo mg.

500 mg.

Total volume

10 ml.

7 ml.

10 ml.

4 mL

It u recommended that in severe delinum four pairs of the intravenous high
potency preparation be injected BTunediately, and that this dose or half the dose
be repeated four- to eight-hourly as retFiired. The rationale of this treatment is
that the vitamin B compounds act as co-enzymes m carbohydrate metabobsm,
so that massive supplies of them wtH correct their inactivation by toxins. Ko
adequate controlled studies of the value of this treatment have been carried out.

DRUG DEPENDENCE

JOS

polyneuritis. It was later realiaed that it was due to alcohol, but that the
same sort of memory defect occurred in subacute brain disease produced
by many different diseases. The clinical picture tvith loss of registra-
tion as its main feature is called the ‘Korsakoff state’ or ‘amnestic
syndrome’, but when there is also a polyneuritis it can be called
’Korsakoff’s psychosis’.

The Clinical Psrturg. — Disorientation for time and place is complete,
but orientation for person is preserved. Despite the gross disorientation
the patient can usually find his way about the ward and his behaviour is
in keeping with the environment.

Memory for knowledge acquired earlier in life is well preserved, but
often there is a retrograde amnesia for events immediately preceding the
illness, which sometimes stretches back to a point many years before.
It is often said that impressibility (registration) is disordered, but
although one of the major disorders is that of ‘minute memory’ (see
p. 48), experiments involving recognition and relearning show that new
memories can be acquired with difRculty but cannot be evoked or
recalled. Confabulation usually occurs, but may not be spontaneous.
In such cases the patient can usually be persuaded to confabulate. The
confabulation covers up the gaps in the memory.

Thinking is disordered in that there b difEculty in changing the
direction of thought, so that all incoming sensations are distorted in
terms of the current train of thought, which only changes direction
when disturbed by some intense stimulus from without or within. The
mood is usually one of euphoria. There is no insight into the disorders
of memory and orientation. The general attitude is one of passivity,
and often these patients are e-xtremely suggestible. Polyneuritis is
usually, but not invariably, present.

Treatment. — It is customary to give large doses of ritamin B complex.

Prognasis.~-This is poor, since some degree of dementia is often the
final result.

Wernicke’s Encephalopathy. — ^Thc direct cause is a deficiency of
thiamine (aneurin). This can be produced by poor diet, excessive
vomiting, or secondary dietary defidcncy due to alcoholism.

Pathology.— Acute haemorrhagic lesions are found in the peri-
aqueductal grey matter in all cases, in the mammillary bodies in most,
and in the dorsomedial nucleus of the thalamus in over 50 per cent of
cases. This is more or less the same as the distribution of gliosis in
alcoholic Korsakoif states. It ts probable that both disorders are due to
thiamine deficiency and the difference between them is merely in the
tempo of the morbid process.

Clinical Picture. — Eye signs are chamcteristic. There is lateral
nj-stagmus and ophthalmoplegia, most frequently a lateral rectus palsy.

106 AN OUTLINE OE PSTCHIATRY

Ataxia 13 well marked and the patient walks on a wide base and tends to
reel.

Spontaneous speech is minimal and there is a strange aversion. The
patient answers questions in a perfunctory manner and cannot focus his
attention on any topic. He may turn over and go to sleep during a
conversation. The typical memory and thought disorder of the
Korsakoff state is often present.

There is, in fact, no sharp boundary between Wernicke’s encephalo*
pathy and the Korsakoff state.

Treatment . — Large doses of vitamin B complex are given. The
administration of thiamine alone might unmask other vitamin
deficiencies.

Outcome . — Death often occurs. In some series 50 per cent died. As
a rule, when the acute signs die aw^ a Korsakoff state is left behind.

Alcoholic Dementia. — This may come on insidiously or may
follow delirium tremens, alcoholic hallucinosis, the Korsakoff state, or
Wernicke’s encephalopathy.

Alcoholic Delusions of Jealousy (Alcoholic Paranoia).— The
alcohol addict may develop delusions of jc^ousy, which may at first only
occur during drunkenness. The condition is often attributed to the
alcoholic’s diminished potency, his inaeased desire when drunk, and
the wife's refusal to luve sexual intercourse because of his lack of
consideration and general unpleasant behaviour when drunk. The
wife's refusal is misinterpreted.

There are probably three different types of jealous alcoholics;
(i) Jealous husbands (lee p. 133); (a) Inadequate insecure persons who
become jealous when drunk. This stops when the patient gives up
drinking; (3) Scluzophrenics who arc also heavy drinkers.

DRUG ADDICTION

Drugs Involved. — There are three main groups depending on
pharmacological effects,

1 . The Analgesics, — Morphine, heroin, pethidine, and other synthetic
drugs.

2. The Euphoriants, — Cocane, Indian hemp, the sympathoininietic
amines, and the hallucinogenic drugs.

3. The Ilypnoltcs . — ^The barbiturates, aliphatic hypnotics, and
meprobamate.

Opiate Addiction-— All the analgesic drugs cause tolerance,
physical dependence, and emotional dependence. Addiction to morphine
will be used as a paradigm.

The Administration of the Drug . — Initially it is taken subcutaneously
and in some subjects this may cause nausea, vomiting, and malaise at

DRVC DEPENDENCE

107

first, but after repeated injections the side-effects decrease in intensity.
The subject drifts off into a light sleep and then wakes and nods off
repeatedly. During the drowsiness, dreams related to the usual
fantasies occur.

Intravenous morphine (‘main line*) produces dizziness, flushing,
itching, and rumbling in the stomach. A sensation occurs in the
abdomen like an orgasm, but it does not affect the genitals.

Symptom during Addiction . — The pupils are constricted, constipa-
tion is always present, and libido declines. Women usually stop
menstruating and rarely become pregnant. As long as the addict gets an
adequate supply of the drug he can carry on with his job and is in fairly
good health. Emaciation is secondary to the use of available cash to
buy drugs instead of food.

The Abttinenee Syndrome . — The clinical features of this condition
are shown in Table J.

Table I. — Tkb Abstine{ce Syndrome

Period op Abstention Symptoms

14-18 hours

Yawning, perspiration, ihinorrhoea, mild lacrimation

Stage 2

18-44 hours

Absolute insomnia, worsening of above symptoms.
Muscular twitchings, aching in legs and back. Hot
and cold flushes.

Patient curb up and covers himself vrith blankets.

Stage 3

36-48 hours

Extreme restlessness. Patient gets m and out of bed.
fetching and vomiting. All other symptoms increase
in severity.

Rapid weight-loss. Extreme misery.

Temperature rises by about i*C.

Blood pressure rises by 1 5-30 tnm. Hg.

Increase of respiration rate

Stage 4

48-60 hours

Peak intensity of all symptoms— may then decline

Stage 5

7-10 days

Objective signs absent.

Insomnia, weakness, jitteriness, aches and pains
persUt for weeks

This syndrome is due to a pl^ological change in the whole of the
nen’ous system. An adequate dose of morphine or an equivalent drug
will reverse the abstinence symptoms completely within a few minutes.
The abstinence sydrome is best treated with methadone linctus (a mg.
in 5 ml.). In Stage i, 10 mg. methadone should be given and 20 mg.
can be given 1 hour later if the symptoms do not subside. If Stage 2

Io8 AN OUTLINE OF PSYCHIATRY

has been reached 20 mg. methadone should be given and repeated in
2 hours.

Other Opiates and Morphine Substitutes, — In general, if a drug is as
effective an analgesic as morphine it is likely to have the same addiction-
producing property.

Addiction to the synthetic analgesics is roughly the same as morphine
addiction, but the intensity of the abstinence syndrome is somewhat
less. This is especially the case wth methadone (physeptone). Heroin,
which is diamorphine, has slight side-effects and is the most popular
drug of addicUon in the U.S.A. The abstinence syndrome is as bad as
that of morphine.

Meperidine (pethidine) is still believed to be non-addictive by some
phy-slcians. This drug taken subcutaneously produces severe diaziness
and elation. As the duration of its action is brief the addict takes it at
2-3-hour intervals throughout the 24 hours. The drug is irritant, so
that indurated patches occur in the skin and muscles and large skin
ulcers may occur. Tolerance is marked and daily doses of 1000-
4000 mg. may be reached. Unlike morphine, tolerance is not complete
and the drug has a toxic effect. Tremors, confusion, risual hslludnations,
and fits may occur. The E.E.G. shows paroxysms of high-voltage slow
tvaves and spike and wave discharges.

Abstinence symptoms are like those of morphine but occur in 3-4
hours and are maximal after 8-12 hours.

The Diagnosis of Drug Addiction. — Isolation will produce abstinence
symptoms; a morphine antagonist %viU produce abstinence symptoms.
Thus nalorphine 3 mg. subcutaneously, followed by 5 mg. in 30 minutes
and 7 mg. 30 minutes later will produce abstinence symptoms in an
addict.

Treatment. — TTie first step is to withdraw the drug. This must
be done in an institution and the patient's physical health should
be good. Methadone given orally is substituted for the opiate
(t mg. methadone = 4 mg. morphine = a mg. heroin = 20-30 mg,
meperidine). Once substitution has been made the methadone is
withdra%vn over 3-10 days, depending on the response. If the patient
is in poor physi<^ health it may be wthdrawn more slowly. Psycho-
therapy is essential and often occupational training may be needed.

Recently Dole and his colleges have introduced ‘methadone
block* as a treatment for heroin addiction. The rationale b to pre\Tnt
the euphoric effect of heroin and the withdrawal symptoms due to the
cessation of narcotic drugs. The treatment begins in hospital when
10-20 mg. of methadone are given daily in divided doses and this is
slowly increased until the blockade level of 80-120 mg. is reached.
The patient is then discharged from hospital. After the patient has

DRUG DEPENDENCE

109

become socially adjusted the need for the blockade is reviewed. Dole
claimed that this treatment was successful in 90 per cent of one series
of addicts.

Until recently heroin addiction was not an important problem in
England and it has been possible for any doctor to prescribe heroin for
an addict. Unfortunately^ gross overprescribing by a few doctors has
led to an extensive black market in heroin and an increase in addiction
among young people, particularly in London. By the time this book
is published only specified doctors will be licensed to prescribe heroin
or morphine for an addict and addicts will be notified to the Chief
Medical Officer at the Home Office.

The Euphoriants. — These drugs are all different in chemical
structure but all produce euphoria and there is no complete tolerance
to them.

Cocaine . — ^The drug is taken as snuff, or intravenously, usually in
conjunction with heroin or morphine. It produces an ecstatic sensation
of extreme mental and physical power, with the abolition of all sensa-
tions of fatigue and hunger. TTie effects wear off quickly in several
minutes and the doses have to be repeated e\ery time the effect
disappears. This causes toxic symptoms such as tachycardia, rise in
blood-pressure, severe sweating, tremors, twitching, muscular spasms,
and occasionally convulsions.

If the drug is taken for some time a paranoid psychosis develops and
the patient belie^'es that he is being watched by detectives, and may
assault innocent bystanden. Formication, the feeling of insects
crawling on the skin, occurs. This 1$ known as the ‘cocaine bug*.

The Sympathomimetic Amines . — Dextroamphetamine sulphate and
methylamphetamine hydrochloride are the drugs of this group which
are most commonly taken. Often barbiturates and/or alcohol are taken
as well. Some tolerance occurs, but toxic effects alwap occur in high
doses. An intake of 2000 mg. a day has been recorded. A paranoid
psychosis indistinguishable from schizophrenia often results from high
doses.

Indian Hemp . — Hashish or marijuana is usually smoked, mixed with
tobacco, in the so-called ‘reefer*. It produces elation and a distortion
of space and time. The conjunctivae are injected and pseudoptosis
occurs. There is no tolerance and the drug does not cause addiction.

Hallucinogenic Drugs . — ^These are also discussed in the chapter
on treatment (see p. 205). Officially, according to the Poisons Regula-
tions (Hallucinogenic Drugs), 1967, the following drugs are included
in thb designation: dimethyltiyptamine, lysergic add diethylamide
(LSD), mescaline, psilocybin, and psilodn. Severe panic, chaotic
behaviour and suidde may occur during the psj'chosts induced by these

110 AN OUTLINE OF PSYCHIATRY

drugs. Permanent schizophrenic psydu»es have been reported, but
experimenting with LSD occurs in the age groups in which echizo-
phrenia is not uncommon. Physical dependence on LSD probably does
not occur, but psychological dependence does. Recently it has been
found that LSD causes chromoramal daiTiage.

The Barbiturates. — Addiction to these drugs is quite oimmon in
Britain but not recognized.

TXe Feature! of the Addictum . — Addiction is likely to occur if the
patient regularly takes o*8 g. or more of a quick-acting barbiturate in
24 hours. The drug is usually pentobarbitone (nembutal}, quioal-
barbitone (seconal), sodium amylobarbitone (sodium amyul), or a
mixture of the last two, marketed in Britain as ‘tuinal*. Slight tolerance
occurs, but the drug has to be taken in doses which just produce a slight
toxic effect, so that dysarthria, ataxia, and slight confusion are usually
present. A slight increase in the usual doses may make the patient very
drowsy or even comatose. The E.E.G. shows the characteristic fast
activity.

Absti/UHee Symptoms . — During the 8 hours following abrupt with-
drawal in an addict there is a general improvement due to loss of toxic
symptoms.

Then anxiety, headache, tremor, muscular weakness, dizziness on
standing, and vomiting occur, becoming btense after 16 hours.

The E.E.G. sho^rs progressive slowing and paroxysmal bursts of
spike and wave or high-voltage slow waves occur. Grand mil fits are
likely to occur between 30 and 48 hou« after withdrawal. Fits arc
followed by confusion, which may either clear rapidly and be followed
by recovery, or worsen, leading to delirium. In one experimental series
60 per cent of addicts had delirium and 75 per cent had at least one f.t.
The delirium is very similar to the condition of delirium tremens.

Tfie Treatment of Barbiturate Addution . — The patient is admitted to
hospital and given pentobarbitone, which is slowly withdrawn over a
period of 10 days. Ewing and Bakewell suggest that drug tolerance
should be tested by giving the patient an oral dose of 200 mg. pento-
barbitone on an empty stomach and assessing the effect after i hour.
If there is no sign of intoxicatton the patient’s daily barbiturate require-
ment is 1000 mg. or more. If he is comfortable but shows lateral
nystagmus, a daily dose of 8oomg. is indicated. Drowsiness, slurred
speech, Romberg’s sign, and coarse nystagmus suggests a dally dose of
500-600 mg. of pentobarbitone. The patient is given the minimum
daily dose which just produces mild intoxication and this dose is
reduced by so per cent daily, lVbn-6ar6i'furate anticonvulsants, serdr
as phenytoin soium o*i g. three tiroes a day, should also be given, but
phenothiazincs should be avoided.

DRUG DEPENDENCE III

Note: If a fit develops in a person with a history of neurosis, one
should always remember the possibility of a withdrawal fit in an addict.

Addiction to Other Hypnotics. — ^Addiction to paraldehyde, chloral
hydrate, and meprobamate can occur. The symptoms are like
barbiturate addiction and the effects of withdrawal are about the same.
Chloral addicts tend to have red puffy eyes. Any drug as effective as a
quick-acUng barbiturate in relieving anxiety will probably be just as
prone to produce addiction.

Psychological Theories of Addiction. —

General Psychiatric Views. — Some addicts are normal personalities
who become addicted due to the injudicious use of analgesics. Others
are neurotics, psychopaths, or people with both psychopathic and
neurotic traits.

Personality Types.* — ^There are five personality types of addicts: —

1. Normal: Addiction is due to unwise use of an^gesics by doctors.

2. Neurotic individuals: They take drugs to relieve anxiety.

3. Psychopathic personalities: Drugs arc taken by these people to
produce elation or a ‘lift’ of some kind.

4. Individuals with both neurotic and psychopathic characteristics.

5. Ptyehoticsx They take the drug to relieve depression.

Psychoanalytic Formulations. — In infancy and childhood there has

been no strong consistent father figure and the mother has been rejecting
and over-protective in an inconsistent way. The fixation point is at the
oral stage of libidinal development. The subject does not learn that his
wants cannot be fulfilled in reali^r, and he regards the mother as an
object for self-gratification. Hus narcissistic orally dependent person
reacts to the world ivith hostility, which may be directed towards the
mother and other women, but may at times be turned inwards as
depression with suiddal ideas. Drug taking is condemned by society,
so that the hostility to society can be expressed in the use of drugs.
The effects of addiction and withdrawal can be seen by the patient as
partial self-destrucdon and expiation of guilt. The actual effect of the
drug is secondary and is really unimportant. Fantasies of castration,
incest, or masturbation may be assodated with the use of a hypodermic
syringe.

Wikler^s Pharmacodynamic Interpretation. — ^Wilder suggests that the
spcdfic pharmacological effect of the drug may help the subject with
his psychological problems. Thus, since opiates reduce primary
drives such as hunger, pain, and sex, and also decrease aggression the
addict will be someone whose main sources of anxiety are assodated with

•The tenns 'psychopath* and 'neurotic* are used here in the standard
Anglo-American lense.

It2 AS OVTLIKB OF FSrCIUATnY

these drives. The effect of the drug is useful to the addict. When
physical dependence occurs a new need for the drug is created, so that
addiction is partly maint^ned by this secondary factor. The immediate
relief of withdrawal symptoms the drug leads the addict to treasure it,

and he then uses the drug for any discomfort. Any unusual situation
requires an injection, so that the addict is ‘conditioned’.

General Social Factors. — Sodal factors determine the av-allability
and the use of drugs in a given cotnmimi^. In Britain where control
of the import of drugs has been strict, addiction for a long time only
occurred among those with access to dangerous drugs, such as doctors,
nurses, and so on. In 1959 there were very fe^v heroin addicts in
Britain under the age of 35 years, but by 1965 there w ere one hundred
known addicts under the age of 20. It was believed that by allowing
any doctor to prescribe drugs for addicts the profit was taken out of the
illegal traffic in drugs, so that drug addiction did not spread. Unfor-
tunately for this long cherished belief heroin addiction 1$ increasing
rapidly among teenagers and young adults in Britain. The source of
heroin has been the gross overprescription of drugs by a few doctors.
Thus the Interdepartmental Committee on Drug Addiction found that
one doctor had prescribed 9 g. of beroin for an addict on one occasion
and 6 g. of heroin 3 days later to replace tablets which the addict said
bad been lost in an aeddertt It is difficult to account for this increase
of drug addiction among young people in Britain. Some believe that Jt
is a reflection of the new 'permissive society’ which has developed in
Britain In the last ten years.

”3

CHAPTER IX

AFFECTIVE PSYCHOSES AND MANIC-DEPRESSIVE
ILLNESS

GENERAL PRINCIPLES

Manic-depressive Disease — Kraepelin isolated manic-depressive
insanity a s a group of illnesses 'which were usually recurrent, in which
recovery usually occurred, and in which disorder of emotion determined
all the symptoms. These illnesses occurred in individuals who showed
some mood abnormality even when apparently well. The term
‘ CTclothymia * has been used as a synonym /or manic-depressive insanity,
although some authors use this word to mean a constitutional disorder
of mood.

Thus manic-depressive insanity consists of mania and/or depres-
sion in an individual with an inherited ^edispositlon to mood
disorders.

The foUotving types of illness may be ob8er\’ed: (i) A single depres-
sive attack; (a) A single manic attack; (3) Recurrent depression;
(4) Recuncnt mania; (5) Circular psychosis, i.e., attacks of mania
and depression at different times; (6) Mixed affective states ; (7) Consti-
tutional exdtenient (hj-perthymia); (8) Cyclothymia, i.e., an dtemation
of mild manic and depressive moods.

Are All Affective Psychoses Manic-depressive? — Ivleist
regarded manic-depressive illness as a bipolar illness, because, either
features of the opposite condition could be seen in any given clinical
picture, or attacks of mania and depression occurred at different times
in the patient’s life. Leonhard, following Klebt, has distinguished pure
melancholia, pure mania, five varieties of pure depression, and five ^es
of pure euphoria from manic-depressive ^sease.

^Vhile it is not necessary to agree wlh this detailed classification of
the affective psychoses, ther e is no doubt that depression (a utonomous
tdj’sthymia) wi^out manic Icatures does occur in some individuals
^|with no family history of manic-depressive disease or mood disorder,

’ who never suffer from mania, and do not have a typical manic-
depressive personality {see p. 1 14)- It does not seem legitimate to regard
these illnesses as manic-depressive.

8

1J4 A>1 OUTLIKC OF PSyCHIATRT

INCIDENCE

The average incidence of afiecUve disorder demanding psychiatric
treatment is 3-4 per 1000 of the population. Depressive, illnesses arc
extremely common.

AETIOLOGY

Heredity, — The tenden^ to mood disorder rather than this illness
as such is inherited. The incidence of manic-depressive illness among
the parents of patients is 10-2 per cent and among children is i2-8 per
cent (Slater, 1938J.

It has been suggested that it is a single autosomal dominant of weak
or variable expression, but it is quite possible that manic-depressive
psychoses are heterogenous genetically.

The Basic Personality. — Four varieties of personality are found
in association with manic-depresave insanity. They are as follows: —

r. The Deprestive Pertonality (dyithymic). — Gloomy, conscience-
stricken individuals, embittered by fears and cares.

a. The Manic Penanalily {hyperthymic). — Cheerful, happy, bustling,
self-confident 'go getter'.

3. The Irritable Persanalily. — Querulous, quarrelsome, embittered,
and easily upset.

4. The Cychthymie Personality.— Mi three of the previous types may
swing into the opposite mood sute for a short time, whereas ^e cydo-
thymiie has mood changes of depression or elation which last for day’s
or •weeks and are never in equilibrium.

The Physical ConstitutioD. — The pyknic body build, as deacribed
by Kretschmer, is Common in roanic-Sepressive insanity’. This is
a stocky build, with a broad, rounded face tvith no sharp features,
a short, massive neck and rotund abdomen, large •visceral cavities,
tendency to fat on the trunk, slender extremities, tapering to small
hands and feet. On the whole, all one can say about body build and
insanity is that the thick-set arc more often found among manic-
depressives and the thin and ill-thriven among schizophrenics; but
there is a marked overlap. Other physica Lfagt ors a re: —

Pace. — Manic-depressive insanity is more common among Jews.

Sex . — ^Admission rates for affective disorders usually show a pro-
portion of 3 females to 2 males-

Physieal Disease . — ^Affective psychoses, especially depressions, may
be released by brain disease, for example, general paralysis of the
insane, cerebral arteriosclerosis, etc.

Endocrines . — Depression andtensionoccurinthe premenstrual period.
Adrenal hormones may cause affective dlsordeia in the predisposed.
Affective disorders are common after childbirth and at the menopause.

AFFECTIVE PSYCHOSES

"5

The Diencephahn. — Foerster {1933) pressed on the intact hypo-
thalamus during an operation under loc^ anaesthesia and elation and
flight of ideas occurred. Manic clinical pictures may occur in dis-
orders affecting the hypothalamus.

Reserpine. — ^This drug is liable to produce depression (autonomous
dysthymia) in the predisposed. It is sometimes given in small doses in
the treatment of hypertension. The depression is not relieved by wth-
drawal of the drug and must be treated as autonomous dysthymia (see
p. 122).

Biochemical Abnormalities. — Coppen and his group have estimated
the changes in the sodium co ntent in the body in depression and mania.
They found a significant increase tn the residual sodium, t\hich is
mainly intracellular although it includes a small quantity of sodium in
bone. The increase in residu al sodium w as much greater in mania
than in depression. A~cH^ge in intracellular sodium in the nervous
system would gi ve rise to a change in th e excitability of the neurones.

Reactive Factors. — Most illnesses are due to the reaction betti'cen
constitutional and externaTlactors. In affective disorders on e must
al^vays look for reactive factors, but if one finds them this does not
exclude physical treatment. The significance of a traumatic event
must be considered from the patient’s point of view. \Vhat may appear
trivial to the observer may be a threat to all that the patient holds most
dear. The term ‘endo genous depress ing’ U implirh

in it is the idea that the depr^ive illness^has occurred independently
of the environment. The present author believes that in many cases
of depression, which respond to physical treatment and have all the
features of so-called ‘endogenous depression’, the illness has been
initiated by some psychological trauma, but runs its omi course to a
large extent independently of the environment. If one neglects these
psychological factors and treats the illness as if environmental factors
have no bearing on it, then it is possible that relapse may occur because
the patient puts lumsclf into a situation which is bound to be stressful.

As pointed out before, much of the argument about reactive and
endogenous depressions is due to the use of the term ‘depression’ to
indicate two different conditions, one an exaggeration of a normal^
state of reactive unhappiness and the other an illness in which the
mood is qualitatively different from normal. In order to avoid this
confusion the present author suggests tliat this latter condition be
■'jCalled * autonomous dysthy-mh^ *. If no provoking cause can be found
it can be called ‘ primary * ana if there is some obvious cause then it
' can be called ‘secondary autonomous dysth)’mia’.

Psychoanalytic Theory. —

The Fixation Point in Depression. — This is at the oral stage of libidinal
development, when the child is dependent on supplies of milk from

AN OUTLINE OF PSYCHIATRY

Il6

outside. Fixation at this stage produces an individual who b unduly
dependent on supplies of affection from others.

Development of the Depression . — ^An experience causes loss of self-
esteem or naicUristic supplies, i.e., supplies of affection which bolster
up the self-esteem. The patient reacts to his loss of the love object
by introjecting, so that he has the fantasy that he has devoured the
ambivalently loved obj'ect. This can be regarded as an attempt to
restore the lost nardssistic equilibrium. The sadistic nature of the
mechanism of introjection gives rises to guilt.

Mourning and Melancholia . — ^\Vhen a loved person dies the lover is
still linked to the lost loved one by a large number of memories. These
ties have to be broken and this b a difhcult and painful process. The
mourner incorporates an image of the lost loved one and the normal
person finds it easier to loosen the uea with an introj'ect than with an
external object. If the mourner was very a?nbi>'alent towards the lost
object, then introjection is not only an attempt to preserve the lost
one but may also be an attempt to destrey the hated object.

Narcissistically orientated persons may unconsciously reproach the
dead person for having left them and at the same time be unconsdeusly
pleased that someone else is dead, i.e., the ‘better them than me'*
feeling. Both these feelings will give rise to guilt.

The reaction to bereavement will be more intense when: (i) The
object has not been loved on a mature level, but has been used as a
source of nardssbtic supplies; (2) Hie relationship with the lost
object was ambivalent; (3) There Is oral fixation nith unconscious
longings for sexualized eating. These characteristics are found in
people predbposed to depresrion.

Jlegrtssion and the Structure 0} the Mind in Depression . — ^Narcissistic
regression occurs in depression, so that object relations are replaced
by intrap^eWe rclarions. However, the superego regresses to its most
primiUve state, in wHch it is extremely cruel and incapable of forgive-
ness, The introject may dther for«s with the ego or the superego,
but in any case the ego is subjected to the sadbm of the superego.

Mania . — The conflicts betiveen the ego and the superego disappear
and the saving of psychic energy b celebrated as a triumph. The ego
Ttbeb against the superego and gets rid of its burden of guilt, or it
feels loved once more, having purged away its guilt.

The same conflicts occur in mania as in depression, but the patient
uses the defence mechanisms of dental and overcompensation. This
idea of the denial of depression In tnanla b sometimes expressed in
the phrase ‘manic defence’.

AFFECTIVE PSYCHOSES II7

CLINICAL STATES

General Symptomatology. — ■TTie symptoms occur in one of three
main spheres. These are: (i) Psychomotor activity; (2) Emotion;
(3) Volition.

If the activity in these three spheres is enhanced then there is a
manic illness; if d epressed. 2 depressive illness. If activity is enhanced
in one sphere and depressed in another then there is a mixed_ affective.
state. VVe c^ now consider; (i) Depression (autonomous dysthymia);
(2) Mania; (3) Klixed affective states.

I. DEPRESSION (AUTONOMOUS DYSTHYMIA)

Mood. — T^e patient look s^ depressed, tired, and self-concerned; the
brows may be wnnkled. He feels disturbed and upset but may reject
the word ‘depression’ as a description of his mood since it means a
reactive state of unhappiness to him. Everything looks gloomy and
hopeless. There may be a feeling of genci^ized insufficiency. De-
pression may be hidden with a great effort, but well-directed examina-
tion reveal it. Classically, diurnal variation occurs but is not
always present; the depression improves as the day goes on.

Motor Activity: Retardation.'— In retarded depression all psycho-
motor activity is inhibited. There is poverty of movement, the pait is
dragging; speech is slow, toft, and monotonous. Stupor may occur,
but is rarely very severe and almost never associated with incontinence
of urine and faeces, which is coounon in catatonic stupor. Sornetimes.
^though.t he , pati ent i3_anxiau8jn d agita ti^. he has a subjective sense
mTetardation.

Motor Activity: Agitation. — ^This is the motor expression of
anxiety, but retarded patients can be anxious, so that there is no strict
correlation between the subjective feeling of anxiety and agitated
behanour.

Agitation ranges from mild restle^ness to ceaseless movement with
hand wringing, skin pi^ng, and utter misery. Pressure pf.speech is
usually present and the individual talks incessantly about the same
topics. He may be importunate and fasten on to doctors and nurses
demanding reassurance and help.

Di fficulty in concentrati on occurs; the patient cannot concentrate on
the t^k in hand ^d cannot sto p thl nking abou t the unpleasant things
he does not wish to think about. Agitation is more common and more
marked in depressions occurring to middle life and old age,

Deperson^zation. — The patient feeb changed and lacking in
proper emotions.

Obsessions. — Obsessional runututions may occur, especially if the
previous personality was somewhat obsessional.

Il8 AN OUTLINE OF PSYCHIATRY

Delusional Ideas. — ^The normal person has basic anxieties, which
are connected with four different aspects of his life. Thus, to a greater
Of lesser degree, he worries about his moral worth, his bodily health,
his finances, and his relationships with others. In depres sion these
worries iruy become so intense that they develop into delusions. Thus
the different contents to depressive delusions are: (i) Delusions of
guilt with a gross exaggeration of worries about one’s moral worth or
immortal soul; {2) H)^ochondriacal delusions, ivith a gross exaggeration
of worries about bodily health; (3) Delusions of poverty, tvith a gross
exaggeration of worries about money; (4) Paranoid delusions, with a
gross exaggeration of worries about interpersonal relations and social
status.

1. Delusiont of Guilt and Self-reproach. — Self-reproach may range
from the mild belief that the patient has let family or his colleagues
down to a belief that he is the wickedest man alive, that he has com-
mitted an unpardonable sin, that he is not fit for decent company, etc.
Self-reproach and guilt may form the basis for suicidal or homicidal
attempts.

2. /{ypachondriasit . — This ranges from vague ideas of ill-health to
finn delusional beliefs of the pre«nwof ^cer, tuberculosis, syphilis,
etc. Reassurance and further Investigation may be repeatedly asked for.
Bowel hypochondriasis is particularly common among older depresstves,
who may believe their bowels are *blocked', etc.

3. Delusions of Poierty.— These are not common, but they do occur
in the middle-aged and in the elderly.

4. Paranoid (Persecutory) Delusions . — Mild ideas of reference
are common, but well-marked persecutory delusions may occur
in severe depresdon. Such deludons are usually understandable on
the basis of guilt: T am a wicked person; others know I am;
therefore they treat me as I deserve; I am to be punished or killed.’
Sometimes the patient resents the persecution and does not have much
guilt.

Hallucinations. — ^These arc rujt common. They are usually re-
proaching voices calling out odd words or phrases such as ‘Rotter’,
‘Kill yourself’, etc. The ‘v oices of c onscie nce’ may _be heard.
Continuous auditory hallucinosis suggests schizophrenia or organic
psychosis. Some patients believe that they smell and it is difficult
to decide if this is hallucinatory or delusional.

Intelligence and Memory. — Anxiety or retardation may hinder
concentration and l eadjo poor intellect!^ performance and memory.

Sufcfde.— This may be the first and fast symptom of depre^' ort. It
occurs when rct^dation is slight and anxiety not ^ grcatT The
retarded depressive cannot begin the attempt and the very' anxious

AFFECTIVE PSYCHOSES II9

cannot think it out or carry it through successfully. Depressives may
kill loved ones; the depressed mother may kill her child. Attempted
suicide or successful homicide may have a cathartic effect and the patient
may feel much better.

Bodily Symptoms, — ^These are as follows: —

1. Anorexia. — Loss of appetite with marked loss of weight are
common. Very rarely there is excessive appetite.

2. Constipation. — This is coirunon and may form the basis of hypo-
chondriasis.

3. Sleep. — In classic, sleep disorder the patient gets to sleep,
but wakes at 2-4 a.m. and lies awake for hours, or the v aria-
tions ar e,; (a) The patient wakes and falls asleep again repeat^Iy
through the night; (6) The patient wakes at 5-6 a.m. and cannot sleep
any more; (c) There may be difficulty in getting to sleep and early
wrJcening.

Note on Involutional Melancholia. — This disorder occurs in the
involution in rigid obsessional personalities with little interest outside
family and home, for example, in a ‘house-proud housewife*. When
full-blown there Is marked hypochondriasis, especially connected with
the bowels, severe agitation, and paranoid ideas. Nihilistic delusi ons,
such as that the patient is dead, everything is destroyed, etc,, m^y also
occur. The previous personality and the absence of genetic loading
separate it off from manic-depressive insanity.

• Differential Diagnosis. —

j. Reactive Depression. — ^This is the natural unhappiness which
occurs in a normal person who has a severe disappointment or in an
inadequate personality reacting to mild stress. The classical symptoms
of depression {autonomous dysthymia) are absent. Usually resentment
and anger are not far from the surface. There is a marked tendenq'
to blame others and no self-reproach or ideas of guilt.

2. Neurotic Depression. — ^This is a tod term since mild autonomous
dysthymias may resemble a neurotic illness, especially if the anxiety
is a presenting feature. Some chronically anxious indi\iduals suffer
from autonomous dpthymia, but to call them ‘neurotic depressivcs’ is
hardly helpful.

3. Schizopltrenia. — Depression in an abnormal personality may be
very atypical. Some depersonalized depressivcs have difficulty in
explaining their strange apparent lack of emotion and the peculiar
change in thrir pcrcepdon rf the worid which occurs in dereaiization.
In some patients delusions of persecution are very marked, but no
other non-understandable symptoms are present {tee p. 126).

4. Anxiety States. — An^ety states may usher in depression or
anxiety symptoms in depression may lead to neglect of depressive

120

AN OUTLINE OF PSYCHIATRY

symptoms, a previously wcH-adapted adult sudd enl y develops an
anxiety 8 tate_oneJ hould look fo ran affe ctive or organic illness .

5 , SymptoTtialie DcpTtisiM , — Cerebral arteriosclerosis frequently
causes depression. General paralysis of the insane, encephalitis
lethargica, and paralysis ^itans may be associated with depression.
The organic illness is usually obvious on physical examination, but
it is advisable to carry out a Wassermann reaction in all cases of severe
depression. Depression can precede obvious signs of arteriosclerosis.

3. MANIA

Mood and General Behaviour. — The mood ranges from pleasant
over-helpfulness to wild, unruly, high spirits. All inhibitions have
disappeared. The patient is domineering and rejects control. He may
suddenly become very irritable or very sad for a minute or so. He
notices the vanities and conceits of others and makes fun of them.
His remarks hurt and are not easily tolerated. The mood may be one
of angry excitement with marked ideas of persecution, such as unjust
detention or certification, etc-

Fressure of Activity.— Patients are overactive ; they undertake a
multitude of things which they cannot caFry through. If the illness is
severe there may be ceaseless activities; they shout until they are
hoarse, and may smash things without reason. They often play tricks
and jokes.

Pressure of Speech. — Patients never stop . talking and s how flight
of ideas in that the connexion between one thought and the next is
not logical, but based o n chance associations and environmental
intluenccs.

Delusional Ideas. — Gran di ose ideas and a general superior attitude
are evident. As they upseT’other peo^c they may resent the natural
results of their own offensive behaviour and believe that others are
against them. They may have e rotic i deas about strangers. Hypo-
chondriacal ideas may occur, but do not have the sense of urgency
which they have in depression.

Hallucinations. — Misinterpretations and illusions are common,
but true hallucinations are rare.

Bodily Changes. — Loss of weight an d early morning vvakening are
common, but unlike the depresrive the patient has a good ap peti^
and looks wel l, with a fresh, youthful appearance an3 quickT^mrceful
movements. I^^mania is severe then exhaustion may occur.

Severity of Symptoms, — In hypomania there are mild overactivity
and cheerfulness which may pass as normal to lay persons. In mania
overactivity may be very severe, and in acute mania life may be threat-
ened from exhaustion and intercurf^ iflseasesi ’

AFFECTIVE PSYCHOSES

121

3. AUXED STATES

Kraepelln (1921) described sue mixed affective states of which only
one^aytated de oression/is at all common. Many of the others are
doutitful varieties, and if they occur, they do so when the patient is
passing from depression to ma ni a or vice yers a. Some patients may
quickly pass from one mood to the other and while in transition show
a mixture of symptoms. Some patients may have a manic illness, but
depressive elements such as hypochondriasis and self-reproach
frequently emerge, making the diagnosis difficult.

PROGNOSIS

General. — Prognosis for individual attacks is good, but recurrence
is common. Mental hospital admission figures suggest that 39-55 per
cent of manic-depressive illnesses are single attacks, hlania probably
very rarely occurs as a single attack. The intervals between attacks of
manic-depressive insanity decline from a median of 4*3 years betsveen
the first and second attacks to 1-7 years between the fourth and fifth
attacks. Depressive attacks tend to occur as the patient grows older
and tend to become longer and more severe with each repetition,
whereas manic attacks remain the same length or even become shorter
with each repetidon.

r.Hnlgfl1 Features. — Oear-cut classical manic or d epressive illness
in a previously good personality has the best prognosis and if tliere
have been previous mental it^esses then they have been typical
affective psychoses. If the previous personality was inadequate and
showed neurodc traits the prognosis is bad. Gross hypochondriasis
and severe depersonalization have been alleged to be poor prognosdc
signs. If these symptoms occur in a typical autonomous dysthymia
this is not so.

TREATMENT vp

Psychotherapy, — ^The nature of the illness must be explained to
the padent and reladves. Firm and repeated assurance with simple
explanadons of symptoms should be given.

Drugs (Symptomatic Treatment). —

1. Hypnotics . — Sodium amylobarbitone gr. 3 or gr. 6 at night, or
gr. 3 on retiring and a further gr. 3 on waking ea rly may be given.
Sodium amylobarbitone gr, 3 and 6<^um barbitone gr. 5 will get the
padent off to sleep and keep Hm asleep, but he may complain of a
'hangover effect’ In the morning. One should be wary of giving prescrip-
dons for Urge quanddes of barbiturate because of the psl^ of suicide.^

2. Day-time Sedation . — Sodium amylobarbitone gr. 1-3 three tirnes
a day or meprobamate 400 mg. three times a day and one hour before

122

AN OUTLINE OF PSYCHIATRY

retiring may allay anxiety. Honever, there is aln-ays a risk of addiction
or habituation, so tliat these drugs should only be given for short
limited periods when anxiety and agitation are intense. Phoiothiaxines.
s^u^ as thioridazine _ioo-200 mg. three times a day, may help in severe
agitation and are not addiction producing,

3. Eup/iffHants . — ^Amphetamines such as methyl amphetamine hydro-
chloride and dextro-amphetamine sulphate 5-10 mg. after bre^ast
and lunch Mere used in the past to raise the patient’s spirits. There is
no ind icatiflnJQday for these drugs and they should never be given in
conjunction with monoamine oxidase inhibitors, because they can
then produce a very marked rise in the blood-pressure. .Methyl
phcrudatsj(ritjdin) is a euphoriant but not an amphetamine. The dose
is 10-20 mg. twice a day.

Antidep«ssive Drags. —

1. Tneyelic Anlideprtstantt . — ^This is a rapidly expanding group of
drugs which are chrmically similar in that they liavc a three-ringed,
struct ure usu ally consisting of two benzene rings which are held
togctKerTiy different types of linkages. In experimental arumaU all
these substances prevent the depletion of catechol amine stores in the
nervous system, which is produced by reserpine.

a. tmipramine {tofrantt)'. This is the oldes t and probably the mo st
effective drug in this group. The dose rngTtmce times a day for
I week, rising thereafter by 25 mg. every second day until a maintenance
dose of 50 mg. three times a day is ma^ed. The drug docs not usually
affect the depression until to days to 3 weeks ha^c elapsed. If at the
end of I month there is no improvement the dose may be increased to
75 *hree times a day. fin ce the depression has been relieved the
drug should be continued at the effective dose for 6 weeks and then
slowly reduced by 25 mg. each week. _If symptoms return , the dose
must be immediately increased to the prerious effective level. Often
the drug causes a marked improvement although some signs of depres-
sion remain. In these circumstances the dose of the drug should not
be decreased until all indications of depression have disappeared.
Elderly p atjenta frequently have aide-effects due to tofranil, so that it
is ad visile to use lo-mg. tablets and a maximum dose of 2o mg. three
times a day. If this dosage is not effective it can be increased slowly to
50 mg. three times a day, if the patient is phj’sically fit and there is no
evidence of coarse brain disease.

This drug produces dizziness, tremor of the hands, attacks of
sireating, dryness of ine month, difEcuJty in accommodation, constipa-
tion, and hesitancy or difficulty in micturition; it may cause epilepsy in
the predbposed. In elderly or btaiD-damaged patients it may cause
dehrium. Drug rashes occasionally occur, but can if necessary be

AFFECTIVE PSYCHOSES

123

controlled by antihlstaminics. The dizziness may be severe, especially
in patients over 60 years of age who are receiving high doses. Some
patients on high doses, such as 250 mg. a day, fell to the ground suddenly
and occasionally frac tured long boi^. This is not likely to occur in
doses of 150 mg. per "Hay in patients under 60 and 60 mg. per day in
patients over 60. Sometimes patients receiving imipramine develop
mania. During the early days of administration of the drug excitation
may occur, so that the patient becomes more agitated and the insomnia
is worse. If there are any signs of agitation, ^ sedative phenothiazine
such as thioridazine 25-50 mg. three times a day may be given or
chlordiazepoxide ro mg. three times a day.

b. Desimpramine (pertofran): This drug differs very little from
imipramine. The dose is the same and it is just as effective. The only
difference is that it is more expensive.

c. Trimipramtne (surmontil) : Unlike imipramine this drug tends to
produce drott-atn ess. The dose is the same as imipramine, but as much

200 mg. can be given daily in divided doses in resistant cases.

d. Amitriptyline (tryptisol, saroten, laroxyly. This drug is as effective
as imipramine, but is also a tranquillizer, so that it i s useful in a gitated
depression. The dose is 25 mg. three times a day, but if there is no
response after 2 weeks, or if the patient is severely depressed the dose
can be increased to 50 mg. three times a day. Like imipramine, the
antidepressive effect does not occur until 10*21 days after the drug is
first tjjcen. The most troublesome side-effects are drowsiness and

intense dryness of the mouth.

e. Nortriptyline (azentyl, alUgrony. This is an effective drug and the
dose is 25 mg. three or four times a day.

/. Protriptyline {eoneordin)-. TTiis is claimed to be an effective anti-
depressive. The dose is 5-20 mg. three times a day, depending on the
severity of the illness.

g. Iprindole {prondoiy. This is a tricyclic compound with a rather
unusual structure. The dose for mild and elderly depressives is
1 5-30 mg. three times daily, starting with the smaller dose and raising
it after 7-14 daj-s. Se^’ere depression is treated wth 30 mg. three times
a day, but the dose may have to be increased to 45-^ mg. three times
a day.

^ Note". If monoamine oxidase inhibitors are given at the same time as
^tricyclic antidepressants severe confusion or even death may occur.
'^'There is, however, one group of psychiatrists who give both drugs at

the same time and claim that this prowdure is harmless and very

effective in the treatment of depression. \Mien changing from a tricylcic
^tidepressant to a monoamine oxidase inhibitor the patient should
ihave no drugs for about i week. When a patient is taking a monoamine
*bxidase inhibitor and it is decided to change to a tricyclic antidepressant

124 AN OUTLINE OF PSYCHIATRY

the paticDt should not take any antidepressant drugs for 14 days,
because it takes this time for the level of monoamine oxidase to return
to normal.

2. Monoamine Oxidase lnh 3 ntors . — These drugs act by preventing
the breakdown of biogenic amines, while the fnc^Cc afiudcpressants
increase the sensitivity of receptors to the effect of catechol ammes and
serotonin. The monoamine oxidase inhibitors prevent the deamination
of pressor substances which are found in cheese, marmite, meat extracts,
and broad beans. If patieats eat these fbodstufls while taking these drugs
severe hypertension, sometimes with cerebral haemorrhage, may occur.
These drugs also prevent the metabolism of pethidine (meperidine) and
if a patient who is receiving monoamine oxidase inhibitors is given
pethidme, coma and death may occur.

a. Phenelzine (nardil): The dose is 15 mg. three times a day for mild
depression, but doses of up to 75 mg. a day can be given in severe
cases. The drug tends to Increase a^tation at first, so that a small dose
of a sedative phenotbiozine or chlordiazepoxide should also be given if
there is any evidence of ablation. The main side-effects of the drug
are dizziness and oedema of the ankles, but occasionally severe hypo*
tension occurs. Rarely it causes manta or severe confusion.

b. Tranyleypromine (pamale)t The dose is 10 mg. ttvice daily for
a or 3 weeks and if there is no effect the dose can be increased to 20 mg.
in the morning and 10 mg. at night. This drug may increase agitation
so that small doses of sedative phenothiazines or chlordiazepotfde
should be given if there are signs of anxiety or agitation. Parstellln is a
combiaatioR of la mg. of tranylcypromine wfh t mg. of trifluoperazine.
Tranylcypromine may produce dryness of the mouth, dizziness,
dro^vsiness, hypotension, and hypertension. Cases of addiction to this
drug have been reported.

c. Actomol {mebanazine): The dose is 5 mg. three times a day, but in
severe depression 10 mg. three times a day can be given. It has the
same side-effects as the other monoamine oxidase inhibitors.

Electroconvulsive Therapy. — This is useful in all severe depres-
sions and the risks are slight. It should be given mth pentothal and
muscle relaxant. At first two or three treatments a week are recom-
mended; the minimal course is probably six and the maximum Uvelve
treatments. Minor transient complications are niemoty^elcct and
confusion, which occur more quickly in elderly subjects. The major
risks are crush fracture of the spine in unmodified E.C.T. and sudden
death from heart disease. Absolute oanffa-rndtcttfons_afg heart fsSace,
recent coronary thrombosis, and intracranial aneurysm.

Prefrontal Leucotomy. — If there is no response to E.C.T. or
only a transient response in depressive illness lasting more than two
years, then leucotomy should be considered, provided that the previous

AFFECTIVE PSYCHOSES 125

personality has been good and there is a good supportive family back-
ground for the patient to return to- The operation should be considered
more quickly in elderly retired patients.

The Treatment of Mania. —

1. Phenothiazines . — In marked excitement chlorpromazine should be
given 50 (occasionally loo) mg. four- to six-hourly by intramuscular
injection. At the same time the drug should be given orally, 25 mg.
three times a day on the first day, 50 mg. three times a day on the
second, and 75 mg. four times a d^ on the third day. The intra -
mu scular administration of the drug can be. stopped as soon as the
patient is no longer excited, and occasional doses be p«ri' iater
if the exdtement worsens. Usually it is not necessary to continue the
intramuscular chlorpromazine longer than forty-eight hours. The oral
dose of chlorpromazine may have to be increased to 4CX>-500 mg. a
day or in rare cases to 1000 mg. a day. Since chlorpromazine causes
severe jaundice, another phenothiazine should be subsututed as soon
as the excitement is under control. Twenty-five mg. of chlorpromazindj
are roughly equivalent to 25 mg. thioridazine (melleril), 2 mg. per-j^t-
phenaztne (fentazin), an<f2'5 mg. of trifluoperazine (stcl^ine). SinceJ
fentazin and stelazine produce Parkinsonism in high doses, it may be
necessary to give antiparkinsonian drugs^ in addition, such as orphen-
adrine hydrochloricie (disipal) 50 mg. three or four times a day, or
benztropine methanesulphonate (cogentln) i mg. three times a day.

2. Haloperidcl (rerencce).— This is not a phenothiazine . In acute
exdtements 5 mg. of this drug can be given intramuscularly six-hourly
and once the excitement is under control 1*5 mg.-3 mg. can be given
orally three times a day. Doses of up to 7*5 mg. a day can be given
without any complications apart from Parkinsonism and torsion
dystonia, which can be controlled with antiparkinsonian drugs. Torsion
dystonia in wluch the neck is twisted and the patient is unpleasantly
exdted also occurs during the administration of perphenazine and
trifluoperazine.

3. Lithium , — ^This can be given as lithium carbonate gr. 10 or
lithium dtrate gr. 20 three times a day. This controls manic cxdtement,
but the therapeutic dose is quite dose to the toxic dose, and it is
essential to maintain a normal salt intake.

4. FUetroeonvultice Therapy . — Repeated E.C.T., such as three treat-
ments a day for the first day, two a day for the next two days, and one
daVy ■wVitTi necessary, witt contioV mama, but there Vs a risk oi terebiaS
damage. This treatment was useful In sc^-ere mania before the intro-
duction of the phenothiazines.

5. Reserpine . — ^This drug, in doses of 3 mg. three times a day, will
control manic cxdtement, but the side-effects and complications are
unpleasant, so that it Isbest not to use it unless all other drugs have failed.

iz6

CHAPTER X

SCHIZOPHRENIA AND PARANOID STATES
THE CONCEPT OF SCHIZOPHRENIA

SailzoPURENiA was ori^ally isolated as an illness which always
caused a deterioration of the personality {see p. 15), Then it was
realized that some patients with typical schizophrenic illness es re-
cover ed completely . Thus Kraepelin (1919) found that z-6 per cent
of lus patients with dementia praccot made complete and lasting
recoveries. If the course of the illness is not used to separate this
psychosis from others then the only alternative is to use some psycho-
logical symptomatological criterion. The only suitable one is that of
'understandabiUty’, i.c., a symptom is schizophrenic if it cannot be
understood as arising emotionally or rationally from the personality and
the affective state of the patient. This approach gives the following
definition of schizophre ntjtj—

* A group of mentaldisordera in which there is no coarse brain disease
anti in which many different dihical pictures can occur. The fonn and
content of some of the symptoms cannot be understood as arising
emotionally or rationally from the affective state, the previous person-
ality, or the current situation, with the proviso that if paranoid delu-
sions arc present the diagnosis esnnot be made in the absence of other
“non-undcrstandablc" symptoms.’

AETIOLOGY

Heredity. — The general risk is o*8 per cent. If both parents are
schizophrenic, then 41 per cent of their offspring will be schizophrenic.
If one parent is schizophrenic then 16*4 per cent of the children will be
schizophrenic and 32-6 per cent will be schizoid personalities. Of the
grandchildren 3 per cent will be schizophrenic. The risk for a sibling
of a schizophrenic is 10 per cent.

The genetics of this condition have already been discussed {see p. 3).

Personality. — An abnormal premorbid personality is often found,
for example, the so-called ’schizoid personriity’. Persons of this type
are shy, quiet, shut-tn, sensirivc individuals who show litt le em otion
and are unsociable. Some patients (30-50 per ccntl ’shbw no ment^

SCHIZOPHRENIA AND PARANOID STATES I27

abnormality before onset. There Is a tendency to be wise after the
event, but schizoid personalities are more common in relatives of
schizophrenics.

Development. — Some workers have shown that broken homes,
overprotcction, or rejection by the mother , and divorce of parents
are found more often in schizophrenics’ family histories. The
parents of schizophrenics have been alleged to be abnormal by many
investigators.

Sovironment. — Paris and Dunham (1939) showed that there was an
excess of schizophrenia in central districts of Chicago and claimed it
was due to sodal isolation. Hare (1956), in Bristol, claimed that It was
partly due to pre-psychotic migration to these areas (fee p. 6). Isolation,
which occurs in emigrants to the U.SJV., is alleged to be associated
tvith a higher incidence of schizophrenia.

^ndocrines. — Schizophrenia is rare in childhood, and its frequent
occurrence in adolescence suggests that endocrine changes may be a
factor. Bleuler (1955) has isolated a variety of schizophrenia which is
familial and assoaated with a familial ‘acromegaloid ’ appearance.

Metabolism. — Metabolic activity of schizophrenics varies between
much wider limits than in normals but no definite patten\ is discernible.
Cold blue hands are frequently seen and patients often look phj’sically
ill. Hoskins (194b) found a lack of response in some schizophrenics to
varying types of stress. His material tvas not homogeneous. Gjessing
found disturbance of nitrogen balance in certain periodic catatonics.

Precipitation.—

^hytical Illnets , — Occasionally infectious illness or childbirth precipi*
tates schizophrenia. However, the superimposition of the sj-mptoms
of organic psychosis on an affective disorder may make the diagnosis
of puerperal psychosis difficult.

l^’chologieal Siresf . — The onset of schizophrenia is occasionally
associated with severe psychological stress. This does not occur in the
majority of cases, Bateson, Jackson, Haley, and Weakland (1956) have
drawn attention to the ‘double-bind’ technique used by the parent or
parents of schizophrenic3.* TTie child is told not to do something, and
threatencd_>\it h_punishment Tf he do^ »<'l'hen the parent gives a
contradictory instruction which is implied but not put into words.
The child is trained to think illogically and in adolescence under the
strain of this double-btnd relationship the child becomes schizophrenic.

Tbtoty. — exlCTids back as fai as tVit
early jiarcissisiic stage. There is therefore a loss of object relations.
Symptom formation thus consists in the reactivation of archaic func-
tions and the conflict is solved by the denial of reality. Fantasies of
world destruction, bodily hallucinations, feelings of grandeur, schizo-
phrenic formal thought disorder, and some catatonic symptoms are due

128

AN OUTLINE OF PSYCHIATRY

to regression. However, the patient tries to restore his object rela-
tions, so that some symptoms are attempts to do this. These are
world reconstruction fantasies, hallucinatory voices, and some cata-
tonic symptoms.

Paranoid Delusions . — Freud believed that these delusions were wap',
in which the patient could deny his \rish for a homosexual relationship. t
The initial thought in the male is, *I love him’; this is denied and the
thought becomes ‘I do nol love him*. This may develop into *I hate
him’, and then ‘He hates me’, i.e., dclusionsj3f persecimop. It may
develop instead from 'I do not Jove him* into ‘She loves him, not me’,
i.e., delusions of ie^ousy . Or it may develop from ‘I do not love
him’ into ‘I love her’, then *She loves me’, i.e,, erot om ania or amorous
delusions. Finally, ‘ I do not love him’ can be denied as ‘ I lore no one ',
which is followed by the thought, ‘I only love myself’, i.e., delusions
of grandeur . ’This theory is facile and far-fetched.

Neo-Freudian Vietes . — Some Freudians, such as Fedem (1952), have
suggested that the ego is not entirely dependent on the id for its
energies. Fedem sees schizophrenia as a breakdown of ego boundaries.

Klein regarded schizophrenia as a regression to the paranoid schizoid
position, where there is a tendency for the ego to fragment.

SYMPTOMATOLOGY
I. Thought Disorder {see p. 42).— ‘

Disorder of the Stream of Blocking, in which the train

of thought suddenly stops and a completely new one begins, is dia g-
nostic of schizop brenia. Inhibition of thought, pressure of tUought,
^ fiight^f ideas 'may occur, but arc not characteristic.

bl Formal Thought Disorder {see p. 46). — This is a gross disorder
of conceptual thinking in the presence of evidence that at some time
in his life the patient had an a dequate intellectual perfor mance. In
the absence of coarse brain disease this disorder is diagnostic of s cfiizo-
phrenia.

.C Alienation of Thought (see p. 44). — Thought deprivation, inser-
tion, and broadcasting a re diagnostic of schizophrenia.
d. Disorder of Thougfit Content — Delusions . —

h Primary delusional experiences; apophany {see p. 44): Apophanous
experiences occur in the acute stages of the illness. However, they are
soon woven into secondary delusions based on mood and hallucina-
tions, so that they cannot be recognized in the later stages of the
disease.

iif Delusions of persecution: These arc based on primary delusional
experiences, feelings of bodily change, hallucinations of all kinds, and
on misinterpretations based on mood and ideas. 'The natural reactions

SClIIZOPHRENrA AND PARANOID STATES I29

of Other people to the patient’s illness are also misinterpreted. Delusions
of persecution by Je^\s, Freemasons, etc., may also occur.

iii. Delusions of grandeur'. These consist in beliefs of omnipotence,
e.g., being Jesus, God, and so on. They may occur early in the iUness
or later on. They cannot be explained as justification of persecution.

iv. Hypochondriacal delusions: These arc based on bodily hallucina-
tions, but may at times be due to thought disorder. Sometimes they
are a presenting symptom,

2. Sense Deceptions. (See p. 35.) —

a. Auditory Hallucinations . —

i. Voices (phonemes)'. Hallucinatory voices in a clear state of con-
sciousness are very common in schizophrenia. They may be clear or
unclear. Voices may talk to the patient or talk about him in the third
person. Runnin g commentary voices n^_occur and are diagnostic.
The voices be^Hunve ^ndTKostile or reassuring. They may give
orders which the patient may or may not carry out. The patient may
hear his own thoughts spoken aloud, so-calle d Geda nkenlautsce rden.
This is diagnostic. The voices may be attributed toTeal or imaginary
people or to machines, such as radio and television.

The voices may be intermittent or virtually continuous, and the
patient then hallucinates during conversation. Frequently the voices
cease when the patient is occupied in work or conversation. Continuous
auditory hallucinations in the absence of organic disease are mostly
likely to be due to schizophrenia.

ii. Elementary hallucinations'. Buzzing, whistling, etc., may occur and
be used to support paranoid delusions about machines and so on.

b. Visual Hallucinations. — Visions occur but usually are distinguished
from reality. Visual hallucinations are not as common as auditory
hallucinations.

c. Bodily Hallucinations . — Sensations of heat, cold, pain, and electric
shock may be felt. Sexual sensations and orgasms may be complained
of. These experiences are felt as foreign and are diagnostic of schizo-
phrenia.

d. Hallucinations of Smell and Taste.— -Those occur in the acute
stage, but are not characteristic.

3. Emotional Disorders. —

a. General Disorders of Mood . — Mood elevation, depression, anxiety,
and perplexity may occur, but are not characteristic. Acute illness
often begins with depression and/or anxiety.

b. Abnormalities of Emotional Expresswn. — Loss of finer feelings for
relatives and unaccountable rages are often an early sign . Character-
istic disorders arc: (i) Flattening of affect ;^2)T:ncongruity of affect;
(3) Stiffness of affect.

9

AN OUTLINE OP PSYCHIATRY

Mifd decrees of flattening and incongruity ore diflicuft to assess and
must be used cautiously in diagnous, since the range of emotional
expression in abnormal personalities is «ry vide. Failure nf ni ppn^
may be diagn ostic or may be due toa failure on the part of the examiner.

4. Motor and"^chaviour Disorders (Catatonic Disorders). —

a. Suhjerlne Fefiinst of Paimity. — The patient feels that his

thoughts, feelings, speech, and actions arc not his on-n, and that lie is
made to cany out these actirttles by outside influences. This may be
interpreted in a delusional tray, yiesc feelings are dia^ mostie of
schizophrenia. ^

b. Excitemrntt. — Senseless excitements occur. The mood is not
cheerful and destruction of clothes, fittings, and furniture occurs.
Mole nt senseless assaults may be made on nurses and fellow patients.
Exatements may be ahon-Ii\-cd or may alternate nilh stupor. Mild
excited states may continue for long periods and take the form of
tearin g, reatless n-andering, or senseless moaning. These states usually
respond to phenotliiazincs and arc not seen very often today.

e. Akinetii and Ohtinuiion. — The pauent is motionless but can be
pushed into action. Movements may begin and then stop suddenly.

5 fi/por.— Patients sit or lie motionless with or without increased
■■ muscle tension. Tlicy do not reply. to Q uestions or react to stimuli and
the fades is expressionless Emotional changes may be seen, sucli as
a transient incongruous smite, and the e> cs may be lb ely. A ' psycho-
logical pillow' is common. Saliva dribbles from the mouth, and there
is incontinence of urine and faeces. Stupor may be interrupted by
excitement or a sudden impulsive act.

e. Other Catatonic Sywpromx.— Negatirism, stereotypies, manner-
urns, wavy flexibility, echolalia, echopraxia, ilfi/jehm, AUtmachen
(co-operation), and parakinesia (see pp. 50-38) may occur.

/. Speech. — Some patients are mute, while others reply to ctery
question with drivel or svith incoherent nonsense. Verbigeration may
occur. Some patients talk past the point {Vorbeireden).

g. Autirm.—TKts is a dctacbment from reality «iih a rdatiic or
absolute predominance of inner life. It is often used in a vague \vay
to indicate that the patient is withdrassTi or has difliculty in making
personal contacts.

5. Disorders of Consclousnes*.— During j^culc shifu the patient
may be preoccupied with vivid bdluciastions and appear disorientated
— the so-called ‘ondroid state*. In chronic patients delusions, talking
past the point, autism, and general disinterest may gT>T ri»c to apparent
disorientation.

6. Disorders of Memory. — No disorders of memory can l>c
found on formal testing.

SCHIZOPHRENIA AND PARANOID STATES I3I

a. Delusional MeTnories. — h delusion may acquire the characteristic
of a memory image, or a delusion may be back-dated.

b. Misidentification. — ^This may be positive or negative. That is,
strangers may be claimed as acquaintances, or vice versa.

c. Confabulation. — Some chronic schizophrenics produce fantastic
confabulations.

d. Apoplianous Memories. — ^An abnormal significance may be attached
to a memory image.

CLASSIFICATION OF SCHIZOPHRENIA

Many different classifications of schizophrenia have been put for-
v^'ard, but Bleuler's modification of Kraepelin’s original grouping is as
good as any other. The ^vidingjines are not_hard and fast, and
patients may beg^n with one form of the disease which may then
develop into another,

1. llie Paranoid Form. — Hallucinations and delusions are con-
tinuously in the foreground in this form of the illness.

2. The Catatonic Form. — ^Motor symptoms predominate in this
variety.

3. The Hebephrenic Form. — In this type there is general deteriora*
tion, in which thought and affeettvi^ are affected without paranoid
or motor symptoms being prominent, although they occur.

4. The Simple Form. — Thought disorder and affective disorder
are present, but paranoid and motor symptoms are absent throughout
the course of the illness.

SPECIAL FORMS OF SCHIZOPHRENIA

Schlzo-afiectlve Illnesses or Mixed Psychoses. —

The problem, — Some patients . have illnesses in which there is a
marked affective component, usually depressive, but there are some
symptoms nhich are nan-understandable suid cannot be derived from
the affective symptoms. These illnesses are probably one of the
following: (i) Depression (autonomous dysthymia) with undetected
organic complications; (2) Depression (autonomous dysthymia) in
abnormal personalities; (3) Psychogenic reactions in abnormal person-
alities; (4) A special illness separate from schizophrenia and manic-
depressive disease; (5) Schizophrenia tvith marked depressive features.

Cycloid Psychoses. — Leonhard has described three cvcloid_psYchose s
which are not manic-depressive or schizophrenic. These psychoses
are bipolar, i.e,, they may show clinical pictures at cither end of a
continuum. The clinical pictures are not hard and fast, so that features
of one cj'cloid psychosis may be found in another.

Anxiety happiness psychosis’. The patient has a mood disorder cither
of anxiety or ecstasy. In anxiety there are ideas of reference and

132 AN OUTLINE OF PSYCHIATRY

sometimes hallucinatory voices and illusions. Often there are complaints
of bodily sensations. In ccsta^ the patient svants to help others and
may have hallucinations of hearing and vision.

Confusion psychosis: Here thinking is primarily affected. In the
excited state there is incoherent pressure of speech, with ideas of refer-
ence and auditory hallucinations. In the inhibited state poverty of
speech, even amounting to mutism, perplexity, ideas of significance,
illusions, and halludnations occur.

ilfo/i7ity p^chosis: Psychomotor activity is mainly affected. In the
excited phase there is hyperkinesia, coruUting mainly of expressive and
reactive movements. In the akinetic state all movements are restricted.
Reactivx and expressive movements are affecTed earlier than voluntary
ones, so that in mild cases reactive movements are absent and posture
and mimicry are rigid, although voluntary movements are carried out

Oneirophrenia. — In some acute schizophrenics there seems to be
a dream-like chang e in con sciousness, which Mayer-Gross called the
oneirmS expenenee. Ke rnnsiSercTlhat it \vas due to intense delusional
experiences and halludnations which occupied the patient's entire
attention. Meduna and McCulloch called schizophrenia with clouding
of consciousness ‘oneirophrenia', and claimed that these patients had an
anti-insulin factor in the blood. This has not been conffnaed.

Latent SchizoptircfUa.—These patients have distorted person-
alities nhich are supposed to be due to an undetected schizophrenic
illness in the past. This is impossible to prove.

FseudoneuroUc Schizophrenia.— This variety of schizophrenia
resembles a neurosis, but anxiety affects all aspects of the psychic life
and many different neurotic symptoms may be present at the same time.
Short-lived psychotic episodes occur in which ideas of reference,
depersonalization, and hypochondriacal ideas are present. This is
probably neurotic pseudo-schizophrenia, as these patients seem to be
psychopathic personalities in Schneider’s sense, who are reacting badly
to stress.

Pfropf or Grafted Schizophrenia. — Some high-grade mental
defectives develop sekizophrenia, so that it is grafted on the defect.
However, some defectives are really childhood schizophrenics, so that
schizophrenia in a defective can in some cases be a shift in along-standing
schizophrenic illness. Further diagnostic difficulties are created by the
occurrence of depressive illnesses in mental defectives. Such conditions
may be atypical because the patient cannot explain his symptoms.

Periodic Catatonia. — Gjesring found that a few catatonic patients
showed phases of cxdtement or stupor in association with a phasic
variation of nitrogen retention. He described types A, B, and C. In
ty-pe A the illness was usually an akiDetic stupor and began just before

SCHIZOPHRENIA AND PARANOID STATES 133

the end of nitrogen retention. In type B the illness began some time
during the first half of nitrogen excretion, and in C it began just before
the end of nitrogen excretion. The illness in types B and C was psycho-
motor exdtement, which was more tdolent the later it began in the phase
of nitrogen excretion. Slow activi^ has been found in the E.E.G.
during the illness. Gjessing believed that the variation in nitrogen
retention was due to phasic variations of thyroid function and that
the illness could be cured by masrive doses of thyroid.

PARANOID STATES

Paraphrenia. — ^This term was first used to designate a group of
delusional patients who showed practica lly^ no disord ers o^emotion
and vol ition. The disease is now generally considereJto Be paranoid
schizophrenia occurring later in life and without se\'ere deterioration
of the personality.

Paranoia. — Kraepelin defined this as ‘the insidious development
of a permanent unshakeable delusional system resulting from internal
causes, which is ac compamed^by perfect preservationjof clear and
orderly thinking’.

Circumscribed delusional psychoses without hallucinations, etc., are
occasionally found but are not common. Some ps)chiatrista consider
such illnesses to be schizophrenic. The romm pnes t variety of this
illness is the ‘ jealous hus ban d syndrome ’. The patient has driusions
of jealousy about hlsTviferbut rio ot her signs of mental illness {see
pp. 86, 106).

Process versus Development {see p. 86).--Some paranoid states
can be considered to be understandable developments of abnormal
personalities. On the other hand, in some paranoid patients there is
a sharp break in the personality. Jaspers suggested that such a sharp
irreversible change was due to a psychic process. As the only non-
organic psychosis which produces such an effect is schizophrenia, then
it can be assumed that schizophrenia has produced the paranoid state.

Paranoid Personalities and Delusional States. —

The Sensitive Paranoid Personality . — This type is often a quiet,
sensitive person who feels he is deserving of better things, but some
disability such as phj'sical deformity, masturbation, illegitimacy, etc.,
holds him back. Slowly the patient becomes more embittered, and
some event which exposes his sensitive preoccupation may act as a
key experience and releases a paranoid state.

The QueruUnt Paranoid Personality . — He is usually a suspicious,
high-minded individual who is always defending his rights or supposed
rights, for example, the ‘banack-room lawyer’ spoiling for a fight.
Sometimes a real or imagined injustice leads the patient to litigate.

AN OUTLINE OF PSYCHIATRY

*34

lie loses, but carries his case from one ojurt to another, often abusing
his opponents and being punished for contempt of court.

Organic Paranoid States. —

Acute Organic Paranoid Slates. — Clouding of consciousness usually
helps in diagnosis, but occasionally transient paranoid states occur due
to organic disease, uitli only mimmal degrees of clouding of consdous*
ness. This may occur during phj'sical illnesses such as coronary
thrombosis, following minor operations or childbirth.

Chronic Organic Paranoid States. — ^Patients with marked non-
progressive brain damage may attribute their diflicuUies to others and
believe that other people are treating them unfairly and persecuting
them.

Paranoid Depressions (see pp.70, 118). — As a rule, ideas of per-
secution in depression can be understood as projected guilt. am
wicked; I deserve to be punished; I am punished.’ Some anxious
depressed patients believe they are being persecuted, protest about the
persecution, and do not believe that they deserve such ill-treatment.
If no other clear signs of schizophrenia arc present then these patients
are suffering from a paranoid depression.

Paranoid Scbizopbreola.— Gassically, there is typical disorder
of thought and affect, but the ilbtess may ^gin as a paranoid state and
typical schizophrenic symptoms may not occur for some time. If there is
an obvious break in the personality, schizophrenia can be assumed.

Schneider has claimed that certain symptoms are diagnostic of
schizophrenia in the absence of coarse brain disease. These are:—

r. ^rtaia hallucinatfans, for example, voices which talk about the
patient in the third person, voices in the form of a running commentary,
hearing one’s thoughts spoken aloud.

2. Delusional perception.

3. Disorders of the possession of thought, for example, thought
insertion, thought withdraival, and thought broadcasting.

4. Experience of influence, i.e., anything in the spheres of sensation,
feeling, thinldng, or somatic activities, which is experienced as due to
foreign influences.

Summary. — A paranoid state may be due to; (a) Schizophrenia;
(b) Depression; (c) Personality development; (d) A reaction to stress
in a paranoid personality; (<) Coarse brain disease.

DIFFERENTIAL DIAGNOSIS

Adolescent Crises. — The adolescent is in turmoil with depression,
ruminations, philosophical ideas, irritalulity, and difHcuIties of affective
expression. Usually there have been diflicult relations with parents
for years, and these are made worse hj the need for independence in
adolescence.

SCHIZOPHRENIA AND PARANOID STATES I35

Hysteria {see p. 78). — A severe variety of this disorder sometimes
occurs in adolescent or early adult females who show severely disturbed
behaviour with violence to themselves and others, and usually risual
hallucinations. Rapport is extraordinarily w ell preserved throughout.

psychopathicPersonalities. — ^Emotionally cold anti>5ocial psycho-
paths may commit violent crimes, but show no evidence of thought
disorder. After violent crimes, espedally murder, many criminals have
no affect- The affect has been di^ciated (see p. 54).

Mania. — Some manics are irritable, interfering, and paranoid.
They misinterpret legitimate attempts to control their unpleasant
behaviour and may insist even after discharge that they were unjustly
detained. In acute mania incoherence of thought may be present
because of the very rapid flight of ideas or intercurrent infection.

Epilepsy. — A schizophrenic-liie paranoid psychosis can occur in
epilepsy, usually in the temporal lobe variety. Jn these cases the E.E.G.
is normal but there is a history of attacks of some kind. Sometimes
epileptic speech and circumstantiality are present. In other patients
catatonic psychoses occur; then the E.E.G. is usually abnormal with
continuous apike-and-wave patterns or repeated sharp waves.

Other Organic States.— Usually there is some indication of
neurological disease in the schizophrenic-like organic states, and
the E.E.G. may be helpful. One must beware of amphetamine
psychosis which can mimic paranoid schizophrenia. A history of
repeated paranoid psychoses with recovery is suspicious of amphet-
amine addiction.*

COURSE AND PROGNOSIS

Course of the Elness. — The majority of schizophrenics develop
defect states which consist of varying degrees of personality impair-
ment, but these terminal states may be arrived at in different wap.

Shifts and Phases . — A shift is an acute episode with ne%v symptoms,
which subsides to leave behind some general worsening of the illness,
while in a phase the acute episode disappears, leaving no defect. Those
authors who believe that schizophrenics never recover do not, there-
for, use the word ‘ phase ’ in connexion with schizophrenia. Sometimes
the patient has a phasic Illness, which later recurs, and runs a steady
downhill course. Other patients may suffer from an illness which runs
a shifting course, so that the defect is worse after each shift.

Process Course , — The word ‘process’ is sometimes used to indicate
a steady downhill course of iHness.

* Amphetamine can be detected in the urine by means of a fairly simple
laboratory procedure.

AN OUTLINE OF PSYCHIATRY

136

Prognosis. — This may be for a pven attack, for the possibility of
recurrence, or for the likelihood of deterioration. The individual
features related to prognosis arc; —

1. Age. — Onset in adolescence or over the age of 40 years indicates
a poor prognosis for recovery, but in the later age-group the chance of
deterioration is slight.

2. Speed dJ Onset. — An acute onset has a good prognosis, while a
slow, ingravescent onset has a very poor prognosis.

3. Personality. — A marked prctnorbid schizoid personality indicates
a poor prognosis.

4. Physique.— A pyknic ph)‘8ique su^ests a good prognosis, tvhile a
dysplastic physique suggests a poor one.

5. Clinical Features. — ^larked depressive features indicate a good
prognosis, and so does an acute catatonic episode. However, affective
blunting is almost always associated with an unfavourable outcome.
The simple and hebephrenic forms liave a poor prognosis for social
recovery.

6. Social and Psychological Background.— If the parents can accept
that the patient is ill and ore prepared to tolerate minor behaviour
disorders, then the arrested schizophrenic may be able to live in the
community. Much depends on the tolerance of the family and the
general social environment.

TREATMENT

In general, the aim is to keep the patient socialized, to arrest the
disease, and alleviate the S}7nptoms with drugs.

Psychological and Social Trcatmcat. — Doctors and nurses
should obtain the best possible rapport with the patient. He should
be reassured and every effort made to understand his difficulties and
to help him solve his problems. All personal contacts should be
encouraged and he should fake part in group activity (see p. 1S9). The
patient should be given a regular steady occupation and, when the
disease is arrested, he should be persuaded to take a job suitable for
his mental state and should be discouraged from overambitious pro-
jects. In some cases the patient may be sent out to trork from the
hospital; it is important to arrange discharge as soon as possible.

The illness must be e.\pl^Red to the family and they should be
advised about the general handling of the patient. Usually he is
admitted to hospital and is sent home on tveek-end leave as soon as
he is well enough. His progress while on leave should be discussed
«ith the responsible relatives. It is important to make certain that the
patient is not being treated as an irresponsible chilo. The psychiatric
social worker can often help the family with soda! and economic

SCHIZOPHRENIA AND PARANOID STATES I37

problems ^^hiIe the patient is in hospital and after his discharge. She
can also help by enlisting all the possible social agencies to help him
and his family. In some cases discharge can be listened by allowing
residence at home and attendance at the mental hospital or at a separate
day hospital during the day. Soda! clubs for discharged patients may
help in building up social relationships.

Physical Treatments. —

ElectroconvuUive Therapy. — ^If the illness appears to be a cycloid
psychosis [tee p. 131) electroconvulsive therapy should be given. This
treatment will produce s^nriptomatic relief of marked depressive symp-
toms and catatonic stupor. The techruque is described later [see p. 210),

Insulin Coma Therapy. — ^This treatment has been abandoned in most
British centres. It has been claimed that it doubles the remission rate
during the first year of illness and increases it to a lesser degree during
the second. The technique is described on p. 209. Recent work
suggests that this treatment is not specific, being no better than barbi-
turate sleep, and perhaps worse.

Tranquillizers: The Phenothiazines. [See also p. 196.) —

a. Chlorpromazine [largactil): This drug can be given intramuscu-
latly to CRcited schizophtenics in the same dosage as in mania (see
p. 225). Usually a daily oral dose of 300-500 mg. is effective in damp-
ing do%vn the sjTnptoms, but doses of 100^-1500 mg. have been given
in some clinics. This drug, tike others in this group, is very effective
in excited patients and in parwoid patients with affect-laden delusions
and torturing hallucinations. Unfortunately, it causes obstructive
jaundice in about 1 cose in 500, so that it should not be given for long
periods. It also causes dermatitis, pyrexia, hypotension, and collapse.
In myxoedematous patients it may cause a hypothermic crisis. Very
large doses may cause pscudoparkinsonism, but this is not such a
troublesome side-effect as it is when trifluoperazine and perphenazine
are given. Some patients become very drowsy on chlorpromazine,
and when the dose is reduced to avoid drowsiness the symptoms
become troublesome again.

b. Trifluoperazine [stelazine)'. In doses of 10-25 ^

will effectively control schizophrenic symptoms. The chief side-effects
are an unpleasant restlessness (akithisia) and Parkinsonism.

c. Perphenazine [fentazin, trila/on): This is effective in doses of 12-

m^. a day, but in some cases mg. a day is nece$sa^% It also tends

to produce akithisia, torsion dystonia, and Parkinsonism, which can
be counteracted by anti-Parklnsonian drugs [see p. 198). This drug
can be given intramuscularly in doses of 4 mg.

d. Thioridazine (melleril): This drug is effective in the same dose
as chlorpromazine. In tery large doses of 1000-2000 mg. a day retinitis

138 AN OUTLINE OF PSYCHIATRY

pigmentosa has been seen. TTjis drug has less tendency to cause
Parkinsonism, but someitmes makes patients very dro^\'sy. At the
time of writing the present author considers this to be the drug of
choice since it is effective but is not likely to produce Parkinsonism.

e. Thioproperazine This drug causes severe neurological

disorders; chiefly, muscular hypertonus, torsion spasm, and severe
Parldnsonism. It is given in doses of 5 mg. three times a day, increasing
by 5 mg. three times a day until the maximal amount of muscular tonus
occurs. Dosage is maintiuned at this level for 5 days, then stopped for
a fetv days until the neurological symptoms disappear. On improve-
ment a maintenance dose of i-io mg. is given. If improvement b not
marked, a further 5'day course at the maximum dosage can be given.

TratiquiUizers: Non-phenothiazine Synthetic Compounds. — Prothi-
pendyl hydrochloride (tolnatc) 240-960 mg. daiiy, and hafoperido!
(serenace) up to 12 mg. daily have all been claimed to be effective in
schiaophrenia,

Reserpine is as effective as the phenothiazines. The dose is 1-3 mg.
three times a day. Many patients feel rrdserablc, depressed, and
sensitive to temperature changes when taking this drug. Parkinsonbm
is usually severe and fits may occur in the predisposed. Water retention
often occurs and may produce heart failure. Ti^ drug interferes with
anaesthesia, and prolonged apnoea may follow E.C.T. with the usual
anaesthesia in a patient taking reserpine. As other drugs are usually
just as effective, there is no reason to use reserpine.

Prefrontal Leucotomy {tee p. zra). — Connexions between the frontal
cortex and the hypothalamus are severed by surgical means. This may
help excited catatonics and tense paranoid patients, but the operation
is falling into dbuse because of the success of phenothiazines.

Thyroid Extract, — Large doses may prevent attacks in periodic
catatonia.

Genetic Prophylaxis. — Even if moral considerations are neglected,
the sterilization of schizophrenics will not prevent schizophrenia, since
patients are subfertile. Only 16 per cent of the offspring of patients
are bom after the illness becomes manifest. As pregnancy and the
puerperium may h3\’e an adverse effect, abortion and sterilization of
the pregnant arrested schizophrenic are recommended. Children of
schizophrenics due to be married may be advbcd that only 3 per cent
of the grandchildren of the patient become schbophrenie.

Personal Prophylaxis.— There b no known personal prophylaxis.
Possibly the encouragement of social activities in all adolescents may
prevent the onset of the illness.

139

CHAPTERXI

PSYCHIATRIC ORGANIC STATES; GENERAL PRINCIPLES
INTRODUCTION

These are mental illnesses which are caused by coarse brain disease;
that is, anatomical and physiological ch^ges^cin be demonstrated in
the brain. The fact that psychotic illnesses resulting from coarse brain
disease are called 'organic’ does not imply that schizophrenia and
manic-depressive disease are not the result of brain disease.

Schneider has called psychiatric o^anic states 'bodily based
psychoses’, but this term is too clurrrsy for use in English. This worker
has divided symptoms in these conditions into obligatory, which always
occur in a given organic syndrome, and facultative, which may or may
not occur. In acute organic psychoses clouding of consciousness is the
usual obligatory s>‘mptom, while in chronic organic psychoses deteriora*
tion of the personality and the intelligence are obligatory B}’mptom 3 .
While this is roughly true there are many exceptions. Disturbances of
consciousness do not necessarily occur in acute organic states. Wieck
has pointed out that there are ‘transit ^dromes’ which are reversible
and in which clouding of consciousness is not prominent.

Facultative ajiuptoms were regarded as being the result of focal
lesions or of individual predispositions. It was believed that the morbid
process might accentuate personality traits or release a constitutional
predisposition to a functional psychosis. The argument that clinical
pictures of functional psychoses were due to the release of inborn
predispositions was often drcular. It may well be that certain combina-
tions of lesions of the brain may be responsible for these clinical pictures.
It must be also remembered that several transit syndromes resemble
functional psychoses and there is no evidence that functional psychoses
are more common in the families of patients with these transit
syndromes.

On the whole, the kind of psychiatric illness produced by (xiarse
brain disease depends on: (i) The speed of action of the morbid
process; (2) The extent and scN'cri^ of the brain damage; (3) The
duration of the brain damage; (4) The presence of focal lesions; (5)
The individual predisposition.

Rather than talk of acute and chronic organic states it is better to
diwde these conditions into rev’ersible and irreversible states {tee

Recovery INSULT Recovery

DEATH ORGANIC DEFECT STATES

(Including focal syndromes
and chronic amnestic states)

PSYCHIATRIC ORGANIC STATES t GENERAL

141

Fig. 1). The reversible states may be conditions in which there is
alteration of consciousness, transit syndromes with no alteration of
consciousness, or functional psychotic clinical pictures. The irrever-
sible organic states may be progressive dementias which lead to death
or organic defect states in which the morbid process has been arrested
and left behind a permanent defect, e.g., an alcoholic Korsakoff state
may not recover and a permanent memory defect %vith slight intellectual
deterioration is left behind and is not progressive because the patient
is in hospital and denied access to alcohol.

CLASSIFICATION

A, Reversible Organic States . —

1. Those with Marked Alteration of Consciousness. —

a. Delirious states — acute and subacute,

b. Organic stuporose states — apathetic confusional states.

c. Organic twilight states.

2. Transit Syndromes. —

a. Emotional hyperaesthetic syndromes.

b. Depressive and manic syndromes.

c. Organic paranoid states.

d. Organic hallucinosis.

e. The exogenous paranoid hallucinatory syndrome.

/. Catatonic syndromes.

g. Expansive confabulatory syndromes.

h. Amnestic syndromes.

3. Functional Psychotic Clinical Pictures.*—

B. Irreversible Organic States . —

1. Progressive Dementia or the Chronic Brain Syndrome. —

2. Organic Defect States. —

a. Non-progressive intellectual defect states.

b. Chronic emotional hyperaesthetic syndrome.

c. Chronic amnestic states.

d. Focal syndromes.

REVERSIBLE ORGANIC STATES

I. Organic States with Marked Alteration in Consciousness. —
These are the commonest reversible organic states, but arc not infre-
quently followed by a transit syndrome in which consciousness is not
grossly disordered.

Acute Delirium. — Here there is a dream-like change in consciousness
in which memory images acquire the same importance as perceptions.
Active and passive a ttenti o n are de creased. The patient b usually
* apprehensive **and may even be terrihed, believing that people are

142 AN OUTLINE OF PSyCIflATBY

trying to kill liiin. Delirium tremens is a good example of delirium
and has previously been described (see p. loj).

Subacute Delirium {The Confusicnal State ). — Here there is a mild
degree of clouding of co nsciousness and the level of a\vareness fluctuates
considcrablyJ~ The patient is* perplexed' 'and disoriented in time and
place, but the extent of the disorientation varies markedly. The
condition becomes worse at night with gross disorientation, restlessness,
and anxiety. Ideas of persecution may occur, especially at night.
Isolated visual hallucinations may also occur at lughL Incoherence of
thought is usually present and can be marked. Sudden changes of
environment beivilder the patient This condition is most often caused
by infection, trauma, and electrolyte imbalance.

Organic Stuporose Stater (Apathetic Cmjusional Slater ). — In some
severe acute inketions, such as typhus and typhoid, there is a general
lowering of consdousness with only a few or no sense deceptions. In
less severe brain disorders there may be a mild general lowering of
awareness and diffioilty in comprehension with no hallucinations.
These patients are not restless or anxious, but somewhat apathetic.
The clinical picture resembles that which is found in progressive
dementia and may easily be mistaken for it TTiis apathetic confusfonal
state is not uncommon following a slight cerebral thrombosis in cerebral
arteriosclerosis. The unwary may mistake this condition for a severe
irreversible dementia and to their chagrin the patient may make an
excellent recovery in a few weeks.

Organic Ttcilight StJtrr.— The field of consdousness is restricted, so
chat all thinking and acting is dominated by a small group of ideas,
which totally exclude all others. In addition to the restriction of
consdousness there is also some degree of douding. Occasionally vivid
visual and auditory halludnations preoccupy the patient, although he
gives no indication of this, but appears bemused and distracted. The
degree of appredadon of the environment is always less than usual,
but a few patients do not appear obviously abnormal to uninformed
bystanders. Such indinduals occasionally make long journeys or
wander about for days,

2. Transit Syndrome. —

EmotionalHyperasthetic Syndrome . — This is a mixed neurotic clinical
picture with anxiety, depression, irritability, difficulty in concentration
and memory, feelings of exhaustion and restlessness, and emotiortal
labili^. It can occur in any i-arie^of coarse brain disease and in chronic
phj’sical diseases, such as pulmonary tuberculosis, which have a general
debilitating effect. It may also occur as an irreversible state in non-
progressive permanent mild brain damage.

Depretthe and Manic Syndromes . — Typical depressive illnesses can
occur in «rebral afterrosclefosis. Addisonian anaemia, general paresis

PSYCHIATRIC ORGANIC STATES: GENERAL I43

and other varieties of coarse brain disease. Manic syndromes arc much
less common in organic states, but th^ do occur, particularly in lesions
affecting the hypothalamus.

Organic Paranoid State, — This is a condition in which there is no
clouding of consciousness but marked ideas of persecution occur mth
no hallucinatory voices. It is an acute condition which occurs after
major surgery or severe physical illness, such as cardiac infarction.
Often the previous personality is paranoid or other^vise abnormal.
This illness occurs in general hospitals and usually lasts a few days.

Organic Hallucinosis. — In this condition the outstanding feature is
continuous hallucinatory %'oice3 in a state of clear consciousness and
delusions of persecution which are a logical outcome of the phonemes.
The commonest cause is alcohol {see p. 104), but it can be the result of
chest infections, carbon-disulphide or carbon-monoxide poisoning,
general paralysis of the insane, and epilepsy among other causes. This
clinical picture is not always reversible and can become chronic in
alcoholism, general paresis, and carbon-monoxide poisoning.

The Exogenous Paranoid Hallucinatory Syndrome. — This syndrome
resembles acute paranoid schizophrenia. The previous personality is
sometimea anankastic vdth some sensitive traits, but some patients are
careless and neglectful. The mood at first is irritated and morose and
later becomes suspicious and anxious. Delusions of persecution occur
and the patient believes that he is about to be evicted, discharged from
work, or shunned by the family. Clear phonemes occur, which are
voices in the form of a conversation and are attributed to real people in
the environment. The patient angrily rejects the idea that the phonemes
are halludiutions. The patient may hear voices talking about his
thoughts, but he does not hear his own thoughts spoken aloud.
Experiences of external influence do not usually occur. This syndrome
occurs in amphetamine addicts and also ts likely to occur in patients
^ho are taking or misusing drugs for the treatment of chronic physical
illnesses, such as bronchial asthma and Parkinsonism. This illness may
occur as a transitional phase benvccn delirium and complete recovery.

Catatonic Syndrome. — Catatonic states of excitement or stupor may
result from coarse brain disease, such as anoxia, encephalitis, and
epilepsy. Wherever possible an electroencephalogram and, if need be,
a lumbar puncture should be performed on a patient ^\ith a previously
normal personality who suddenly develops catatonic stupor. Another
simple test is to administer intravenous sodium amyiobarbilone very
slowly and cautiously. If the catatonic stupor is due to coarse brain
disease the stupor will become more profound, while if it is a schizo-
phrenic catatonic stupor the mental state may impro\e dramatically or
at least it will not worsen. Catatonic stupor may be the result of 'petit

144 OUTLINE OF rSYClIIATRY

mal status’ in t^hich there is a continuous spike and t\-ave discharge in
the electroencephalogram.

The Expantiie Cemfabufatory Syndrome, — Classically this occurs in
general paralysis of the insane, but it may occur after head injury and in
typhus. For c.xample, an i8->ear-old youth sustained a sex ere head
injury and afterafexv days he developed the idea that he was ‘Batman’
and had given birth to hundreds of ‘bat babies*. He also gave garbled
accounts of events involving the medical staff and his employer.

The Amnestic Syndrome , — ^Th« condition has already b«n described
in detail in the chapter on alcoholism (see P.ID 4 ). The characteristic
features arc disorientation for time and place, the Joss of registration of
new memories, retrograde amnesia of some degree, confabulation,
‘ tram-line thinking and euphoria. A large number of different varieties
of coarse brain disease can produce this syndrome. Apart from alcohol
the commonest are brain injury, brain tumours, subacute inflammations
of the brain, and dementing processes.

3. Functional Psychotic Qinlcal Pictures. — Depressive, manic,
or schiaophrenic clinical pictures may occur in coarse brain disease. It
is usually claimed that this is the result of the release of an inhented
predisposition. M. Bieuler and his collaborators claimed that when
manic-depressive or schizophrenic clinical pictures were associated
with a cerebral neoplasm the mddence of these mental illnesses in the
family w*as much higher than in the families of patients with cerebral
tumours and no mental illness. These findings do not agree with the
present author’s clinical experience. As far as schizophrenia is con-
cerned Bleuler’s findings are doubtful because schizophrenia is grossly
overdiagnosed in Switzerland.

IRREVERSIBLE ORGANIC STATES

Progressive Dementia. —

Dejiniliott . — ^This is an irreversible intellectual deterioration caused
by coarse brain disease. The term should not be applied to reversible
organic states in w'tuch there is an apparent intellectual deterioration.

Aetiology . —

1. InfeeiioTS of the brain and its coverings : —

a. Acute, as in encephalitis and meningitis.

b. Subacute, as in encephalitis.

e. Chronic, as in syphilis and encephalitis lethargica.

2. iifetabolic and biochemical disorders:—

a. Anoxia, including h)-poglyc3emta.

b. Vitamin dcficicndes, for example, pellagra and \\’ernickc's
encephalopathy.

3. Toxins: Heavy metals and other toxic substances.

PSYCHIATRIC ORGANIC STATES; GENERAL I45

4. Gross physical damage to the brain.

5. Epilepsy : This is probably due to the effects of repeated anoxia.

6. Vascular disorders’. Arteriosclerosis is the most important vascular
disorder which causes dementia,

7. Degenerations of the brain : —

a. Idiopathic, in Alzheimer's disease and senile dementia.

b. Inherited, in Pick’s disease, Huntington’s chorea, and other
inherited disorders of the nervous systenu

8 . Neoplasm.

g. Demyeltnaling diseases of the nervous system.

Onset. — In the early stages a confusional state or an amnestic syn-
drome may be present. The speed of development of the dementia
determines the presenting symptoms. Changes take place in memory,
intellect, emotions, and personality.

Memory . — Memory for recent events is worse than memory for
remote events, and the loss of memory is often the earliest sign of
illness. The patient may compensate for some time by using a note-
book. A true amnestic state may occur.

Intellectual Changes. — In the early stages the patient tires easily in
tasks involving abstract thought. Gener^ information becomes faulty
and the individual becomes slow and muddled in the simplest intel-
lectual tasks. Perseveration occurs. Speech deteriorates and the word
store becomes less. At first patients are often verbose and repetitive,
but in the end only a few odd w'ords may be left at their disposal.
Delusions may be caused by lack of understanding of the environment,
by the reaction of the individual to his loss of ability, by the mood
change, and by hallucinations. Paranoid and hypochondriacal delusions
are not uncommon. Grandiose delusions occur if the mood is manic
(classically, of course, in G.P.I.).

Emotions. — In the early stages the patient may become anxious and
depressed when he has some insight into his lack of ability. Depression
is common at the onset of arteriosclerotic dementia and Alzheimer’s
disease. Mood changes are often fleeting, but sustained mania or
depression may occur. The premorbid emotional behaviour of the
patient may be accentuated. Usually there is a blunting of feeling with
irritable behaviour. Emotional lability is common; tears or laughter
(especially tears) are provoked by a dight emotional upset or by no
obvious cause. Apathy or childish euphoria is the final result.

Personality Changes and General Behovtour. — A foss of inhibition
occurs, which may lead to crimes or sexual misbehaviour. Excessive
sexual demands may be made on the partner, heavy drinking may
occur, and brutality towards wife and children may be displayed on
the slightest provocation. There is a lack of cleanliness and care in

146 AN OUTLINK OP PSYCHIATRY

dress and hjgiene. Urinary incootinenoe oarurs sooner or iater, and
the patient may indulge in silly childish pranks.

Other Psychiatric Symptoms. — ^Hallucinations of any kind may be
present, depending on the basic morbid process. Orientation for time
and place is alwaj-s faulty.

Neurolcgical Signs and Symp/oms.—Ep'Jeptic fits are frequent trilh
other physical signs, depending on the pathological basis of the
dementia.

Outcome. — ff the process cannot be arrested the patient will die in a
period of years from intcrcurrent infection or vegetative extinction.

Organic Defect States. — ■

Non~progressive Intelleclual Defect States. — These are most likely to
be found after treated general paralysis of the insane and severe head
injuries. Often there is also a mild focal sj^ndroroc such as lack of
dnve due to a frontal lesion. The patient's previous personality may
pvc rise to a psychogenic overlay. Thus an hysterical personality tvith
chronic non-progressive brain damage may have gross conversion
hj-steria or behave in a very histrionic way, whereas a paranoid person-
ality may develop ideas of persecution and blame others for the
nustakes which are the result of his intellectual deterioration.

The Chronic Emotional HyperaestheiU Syndrome. — This does not dllTer
from the clinical picture described above. It is not uncommon after
head injury.

Ckronte Amnestic States. — ^The clinical picture b that described on
p. 104. Intelligence tests show some degree of intellectual deterioration,
but the memory dborder is much greater than that which would be
expected from the slight intellectual defect. The commonest cause of
this condition is alcoholbm.

Focal Syndromes . —

Frontal lobe syndromes'. Acute lesions of the dorsolateral frontal
regions may give rise to poverty of movement, which may increase to
a catatonic-l^e immobility, with incontinence of urine and faeces
associated with apparent indifference. Acute lesions of the orbital
region of the frontal lobes lead to affective overexcitability, irritability,
and fearfulness. These pafieocs tend to have angry outbursts, negati-
vistic behaviour, a tendency to siDy joking [Wilsebuekt), and gradually
lose all inhibitions. In chronic lesions there is a silly euphoric mood
with little sense of illness. Disorders of volition also occur. These
patients are unable to persevere, unable to make decisions, and lack
For^ght It has been dsiaicd that the dorsal part oi the frootal lobes
is concerned with spontaneous drives, and the basal part with emo-
tional life. The cheerful euphoric moods of some cases of Pick’s
disease and G.P.r. have been correlated with the presence of severe
lesions in the orbital regions of the frontal cortex.

PSYCHIATRIC ORGANIC STATES: GENERAL I47

Temporal lobe symptom: Halludnatory phenomena are observed
in temporal lobe lesions. vu, jamais vu, and various emotions
may persist for short periods. Hallucinatory smells, visions, noises,
and voices may be present. Hallucinations of memory — so-called
‘flash-backs’ or psychical illu^ons — also occur.

The amyostalic syndrome and brain-stem syndromes: The Parkin-
sonian picture of rigidity and mask-Hke facies is associated mth oculo-
gyric crises. These latter may be linked with perseveradon of thoughts,
compulsive thoughts, memory Images associated with marked anxiety,
or a diffuse anxiety. There is also a bradyphrenia, i,e., a slowing of
all mental activity. This condidon was produced by encephalids
lethargica affeedng adults, but, if it attacked children, it produced
severe disorders of the personality often without a severe amyostatic
syndrome. These children became coM, callous, and brutal, and often
showed sexual abnormalides.

Patients ttith lesions of the globus pallldus and the structure around
the walla of the third ventricle nuy suffer from visual halludnadons.
Some patients with midbrain lesions have repeated, vivid, hypnagogic
hallucinations, while others may confabubte. Manlc-like states with
flight of ideas may be observed in associadon with hypothalamic
lesions. Disorders of appedte, fluid intake, sexual behaviour, and
sleep may also occur in such lesions.

CHAPTER XII

psyanATRic organic states: spEcinc
ILLNESSES

ACUTE INFECTIONS OF THE BRAIN AND
ITS COVERINGS

Acute meningitis and encephalitis cause delirium or a subacute confu-
sional state. In tuberculous meningitis treated with streptomycin
amnestic states are seen during the period when the patient is critically ill.

In acute encephalitis sometimes a catatonic clinical picture is pro-
duced. Encephalitis lethargica occupies a special position in psychiatry
because of the unusual mental disorders which occur in the chronic
state. The acute illness occurred in Britain from 1917 to 1930, and
consisted of a large number of different clinical pictures, usually
associated trith sleep disorder.

In the chronic illness, _ Parkin80Qismj in which the rigidity is more
marked than the tremoiv occurs. 'Hte other striking feature is the
oculogyric crisis, in which the eyes are deviated in one direction,
usually upwards, for periods of time nngtng from a few seconds to
several hours. These crises raay be associated trith forced thinking,
and the patient is usually anxious and disturbed during the attack.
General changes of beha viour also occur, such as impulsive aggression,
self-mutilation, suiddal attempts, and Sexual perversions and crimes.
Post-encephalitic children became restless, aggressive, and depraved
in their ^haviour. They showed behaviour similar to the severely
disturbed aggressive psychopath and were just as foresightless and
uncontrollable.

GENERAL PARESIS

General Points. — This illness has played an important part in the
history of psychiatry, because it was the first serious psychological
illness for which a definite cause and an effective treatment were found.
Today, in Western Europe, the disease is not common. It must be
remembered that general paresis is diagnosed, not on the psychiatric
picture, which is very variable, but on the serology and special findings
in the cerebrospinal fluid. Although the primary cause is the Treponema
pallidum, it is not clear why some infected patients develop general
paresis and others do not.

PSYCHIATRIC ORGANIC STATES: SPECIFIC 149

The Clinical Picture. —

Prodromal Symptoms. — General fatigue, disturbed sleep, headaches,
intolerance of alcohol, and other general neurotic-Iike symptoms may
be present before signs of dementia become obvious.

The General Clinical Picture. — ^The picture is that of a f^rly pro-
gressive dementia, but the tempo of the deterioration of the personality
varies considerably. Often memory is poor, even when there is still
a reasonable amount of general knowledge. There is usually a general
indifference to gross intellectual errors and a mild euphoria, often
with marked lability of affect. Peculiar bemused states of cxinsdousness
occur in which the patient looks strange and may be thought to be drunk.

Accessory Symptoms. — So far the simple dementing form, which Is
the most common variety, has been described. Slightly less common
is the euphoric form in which the patient is cheerful and has ideas of
self-importance. Even less common is the expansive variety in which
there are fantastic delusions of grandeur. In the present author’s experi-
ence the depressive picture is not uncommon in this disease. Usually
the dementia is obvious and the depressive mood is shallow, but
occasionally the depression is indistinguishable from autonomous
d>’3thymia and the positive blood Wassermaiin reaction is unexpected.
Sometimes the illness presents as an acute confusion with or without
severe excitement and rarely a typical paranoid schizophrenic clinical
picture is seen. In patients with rapidly progressive brain changes
catatoruc symptoms may occur. These are usually transient, but
occasionally they last for a long time.

Costroem found hallucinatory voices in 6 per cent of his patients,
and in many of these the voices began after malarial treatment.

Physical Signs and Symptoms. —

Neurological Signs. — Argyll Robertson pupils, progressive spastic
dysarthria, tremor, and upper motor neuron weakness are the character-
istic features. Sometimes the knee- and ankle-jerks are absent and the
plantar response is extensor, i.e., tabopar esis is present Occasionally
aphasia, apraxia, and agnosia' arc present early in the illness. Epileptic
fits are common, but so are congestis'e or apoplectiform attacks. In
these there is a brief period of unconsciousness followed by focal
neurological signs which last for some days.

Disorders of Mimicry. — ^The face loses its wrinkles and becomes
exp ressi onless. The general posture is slack, and movements become
awkward and wooden. The normal play of mimicry and gesture dis-
appears.

Atypical Forms. —

Lissauer^s Type. — In this rare form the pathological changes arc
predominantly focal, so that focal signs and congestive attacks dominate

AN OlfTLfNB or rSVCIUATRV

*50

the clinical picture. Tlic mental and physical deterioration progress
fairly slowly.

Juvenile General Paresis . — ^The picture is one of simple dementia,
but grossly disturbed behaviour, including scJiiaophrenic-liltc dinical
pictures, may occur. If grandiose ideas appear they arc very puerile.

Treatment. — Large doses of penicillin, such as Goo.ooo units of
procaine penidllin per day for 20 days, are usually effective. Tliis, of
course, only arrests the dementia, and the patient is left with some
degree of non.progresiir'c b«m damage. Therefore, apart from
specific treatment, social readjustment and occupational retraining may
be needed.

PSYCHIATRIC DISORDERS IN EPILEPSY

Auras,— Someb'mes the aura which ushers in the fit U a hallucina-
tion, or a mood. Sometimes the change in consciousness due to the
fit is sliglit and unnoticed, and occasionally the aura occurs without
the fit. In such cases the unwary examiner may assume tliat the strange
psychological symptom Is neurotic or simulated.

Ptycbologica! Attack Disorders.—

Utal Afoodt.— Some patients %vith temporal lobe foci have mood
states lasting for a minute or so in lieu of a fit. Tlie mood may be
depressK*e, anxious, euphoric, or very unplrasant.

Psyehamotor >I//tffAr.— These are short-lived rpisodes of abnormal
behaviour associated with an epileptic discharge in the E.E.G. This
disorder occurs in patients with temporal lobe foci. They are often
aggressive, behave strangely, and may have hallucinations and delusions.

Uncinate Fits . — ^The patient passes into a 'dreamy state' which is
ushered in by 3 hallucination of an unpleasant taste or smell, such as
burning rubber, paint, or stale cabbage wTitcr. During the attack visual
and auditory h^lucinations often occur, sometimes with so-called
‘hallucinatory memory flash-backs’. Diji w and i/ji riot experiences
arc commonly found in temporal lobe epilepsy, as are states of bewilder-
ment, depression, anxiety, and euphoria during the attack.

Post-epiUptie Automatism . — Sontc degree of confusion Is nearly always
present immediately after recovery from a fit. In a few cases the con-
fusion is quite marked; the patient may cany out fairly complicated
aaions for a fe\v minutes and is often surprised at the situation in which
he finds himself when be fuHy recovers tonsdousness. Antisocial acts,
such as stealing or indecent behaviour, may occur during such states.

Episodic Psychiatric Stales. —

Cmfusional Slates . — ^Typical delirious and subacute delirious states
can occur in epileptics. At times these patients may be very excited
and riolent. The confusion may be due to repeated fits, which may be

PSYCHIATRIC ORGANIC STATES: SPECIFIC

subclinical, or it may be due to continuous cortical dj-srhythmia. In
some patients clinical pictures resembling catatonic stupor may occur.
Continuous spike-and-wave discharges in the E.E.G. (so-called ‘petit
mal status') are usually associated \dth stupor.

Ticilight States . — ^These may follow on a fit or may begin suddenly
and end with a fit. C onsciousness is restricted (see p. si) and dom in-
ated by a few ideas, delusions, or visual hallucinations! SmjcHI

also occur. Thought proceeds in a slow, sticky way which has

called ‘adhesive’. Once they arc engaged in a conversation patients
tend to continue talking interminably and it is difiicult for their victim
to break off the conversation, yhev are self-centred, self-riyhtem i^
awkward, irritable people. Religiosity is common, and they are often
oily, sanctimonious humbugs.

Dementia . — Some degree of dementia is always, associated with
epileptic personality change, but some epileptics show very gross
dementia and become Adrtually mindless. s

The Temporal Lobe Personality . — Many patients with temporal lobe
epilepsy have an abnormal personally tvhich is easily recognized by

• There is a tendency tc
n epilepsy.

n ‘twilight state’ for any episodic psjchosii

1^2 AN OUTLINE OF PSYCIIIATRV

Ihe expert but is very difficult to describe. They tend to be chronically
uncertain and at times are unable to make decisions and are very easily
inffuenced. There is a general attitude of mistrust and a difficulty in
making personal contacts. These patients seem unable to relate them,
selves to the environment, to ev^uate experiences, to fit them into
their personality, and to elaborate their own thoughts and actions.
It is as if all the necessary constituents are present for rational behaviour
but somehow they do not manage to be integrated. Depression is often
complained of but the patient does not convey the feeling of depression
to the examiner. Sulddal attempts, which are usually difficult to
understand and seem to have little relation to the alleged cause, are
not uncommon, Hj’pochondriaris is common, but there is a lack of
suffering.

EFFECTS OF COARSE PHYSICAL INJURY TO THE
BRAIN

The psychiatric sequelae of brain injury maybe classified as follows;—

1. Immediate sequelae; —

a. Acute confusional states.

b. Amnestic states.

2. Late sequelae:^

a. Unequivocal organic states.

b. Functional ptychiatric disorders.

1. Immediate Psychiatric Sequelae of Braia Injury,—

a. Acutt Cofi/ushnal FoUoiving a head injury consciousness

is often lost for some time. This state of concussion is probably due to
the simultaneous discharge of all cortical neurons and a reversible change
in the reticular system. Consciousness may return suddenly or there
may be a period of confusion before consciousness is absolutely dear.

b. Amnestic States. — In severe injuries the confusional state may last
for some da^ and be followed by an amnestic state which may last for
days or a few weeks.

2. Late Sequelae of Brain Injury.—

a. Unequivocal Organic States. — ^There are three types of unequi-
vocal organic states: —

i. Personality change and dementia.

ii. Epilepsy and epileptic ptychoses.

iii. Acute and subacute organic states due to chronic subdural
hacroatomata.

i. Personality change and dementiai Sometimes a ty-pical frontal
lobe syndrome occurs. Many patients become morose, irritable, de-
pressed, and bad-tempered, with aggressive outbursts. Others may
show emotional lability.

PSYCHIATRIC ORGANIC STATES: SPECIFIC ^53

Dementia may occur after severe head injury. Punch-drunkenness
or traumatic encephalopathy is a dementia due to repeated brain
damage inflicted in the course of boxing, which passes as a sport in
the Western world. These patients have slurred speech, poor memory,
defective intelligence, unsteadiness of the arms and legs, and tremor
of the hands.

ii. Epilepsy: This may follow closed head injuries but is more com-
mon after penetrating head wounds. It is no different from ‘idiopathic’
epilepsy and the usual psychiatric complications of epilepsy can occur
(lU p. 150).

iii. Subdural haematoma’. This is an accumulation of blood in the
subdural space, produced by head injury, often of a trivial kind. It
can also occur in diseases which cause excessive bleeding. Symptoms
may follow the injury immediately, but are often delayed for weeks or
months, possibly when the head injury has been forgotten.

Acute deliria, amnestic states, or a chronic confusional state resem-
bling dementia may occur. Headache and clouding of consdousness
are the outstanding symptoms. The level of consciousness may
fluctuate markedly, so that the patient may be comatose, but within a
few hours may be fairly well. Even when consciousness is not obviously
disturbed the patient is usually dull and apathetic.

Localiaing neurological signs are usually absent, but pareses, pupil-
lary abnormalities, mild aplmlc disorders, and papllloedema can occur.
The protein content of the cerebrospinal fluid is usually raised, and
so is the pressure, although this can be normal or low. In the E.C.G.
there may be an area of electrical silence, or an excess of slow activity
over the haematoma.

Subdural haematoma should always be considered when there are
fluctuating mental symptoms associated nith severe headache or
where there is a rapidly developing apparent dementia.

b. Functional Psychiatric Disorders. — ^There arc four types of func-
tional disorder: —

i. The post-concussional syndrome.

ii. Psychological reactions to the effects of brain injury.

iii. Depression.

iv. Schizophrenia.

1. The post-concussional syndrome: These patients complain of head-
ache, jumpiness, dizziness on stooping, depression, irritability', and
intolerance of noise. In many cases ojmpensation is a complicating
factor and, in fact, exactly the same symptoms can be found in compen-
sation neuroses in which there is no head injury. It is possible that in
some cases there is some generalized bnun damage, but it is unlikely
that it plays more than a minor part in the production of the symptoms.

154 AN OUTLINE OF PSTCUIATIIY

ii. Ptychohgical reactions to brain iigury: Refusal to accept the intel-
lectual defect produced by brain injury may lead to a paranoid state
(see p. 133).

iii. Depression'. This may be a reaction to severe brain damage or a
dysthymia due directly to the brain damage. Suicide is more common
in the brain-injured than In the general population.

iv. Schhophrenia: Tliis can follow head injury, but must be distin-
guished from organic hallucinosis and epileptic paranoid psychosb. If
schizophrenia follows the head injury immediately, or without an inter-
vening period of normality, then it must be attributed to the injury.

THE PRESENIU2 DEMENTIAS

General Discussion. — ^These dementing illnesses occur before the
age of 60 years. Dementias arc degencralive disorders of the central
nervous system, which can be classified from the psychiatric point of
view in the following way: —

1. Degenerations in which the psychiatric symptoms are most
prominent: —

a, Alzheimer’s disease.

b. Pick’s disease.

e. Rare varieties of presence dementia.

2. Degenerations in which neurological and psychiatric symptoms
are of equal importance.'—

a. Huntington’s chorea.

b. Jakob Creutzfeldt disease.

e. Hepatolenticular degeneration (Wlson’s disease).

3. Degenerations in which neurological signs are outstanding, but
which can be associated with dementia.

I. Degeuerations in which the Psychiatric Symptoms are
Most Prominent. —

a. Alzheimer's Disease . — ^This is the commonest presenile dementia,
usually occurring beWeen 40 and 60 years of age, but is occasionally
seen in adolescents and young adults, and very rarely in children.
Many neuropathologists ^lieve it is an early manifestation of senile
dementia. It probably has a multifactorial genetic basis.

Pathological changes'. The brain is shrunken, with wde suld and
enlarged ventricles. IVUcroscopical investigation reveab a decrease in
the cells of the cerebral cortex, espedally in layers 3 and 3. Degenera-
tive changes are seen in the remaining cells, "nie outstanding features
are aegj'Kfpkllic plsqaa and Alzha/sePs ntuccBbcillary dranges. Tbc
plaques vary in size from 15 to 150 (i in diameter and contain granular
or fflamentous material which stains well with silver and has the
staining reaction of amyloid. Varying degrees of proliferative and

PSYCHIATRIC ORGANIC STATES: SPECIFIC 155

regressive changes may be found in the glial celb at the periphery of
the plaques.

In the neurofibrillary change the fibrils of the nerve-cells become
irregularly thickened and stick together. These altered fibrils stain
very well with silver stains. Spirals^ loops, strands, and baskets of
altered neurofibrils are seen.

Psychiatric clinical piciurei TTie course of the illness can be divided
into a stage of personality change, a stage of intellectual and speech
disorders, and a terminal utter dementia. The clinical picture of
dementia has already been described {see p. 144). The special features
of Alzheimer’s disease are: (i) Depression and anxiety, often occurring
in the early stages, but ten^ng to be transient; (2} Disorders of space
and time, i.e., parietal lobe symptoms, usually occurring early in the
illness; (3) Aphasic disorders, which wt>uld be expected from diffuse
parietotemporal lesions, marking the onset of the second stage; (4)
Reading and writing are more disturbed than speech; (5) Echolalia and
the senseless repetition of odd words or phrases are both quite common ;
(6) Palilalia and logoclonla (see p. 60) arc usually present.

Neurological signs: Muscle tone is often increased In the early
stages, but the rigidity is neither clasp-knife nor cogwheel; epileptic
fits occur in over 25 per cent of cases; extrapyramidal signs occasion*
ally occur; the gait is often stiff, awkw'ard, and unsteady. In the final
stages sucking reflexes and forced grasping and groping are frequently
present.

Courseof theillness: Death usually occurs from Intercurrent infection
within 2-10 years.

4 . Pick's Disease. — This is much rarer than Alzheimer’s disease, but
like that illness it is more common in females. It usually occurs in
middle-age, but can occur in youth and old age. It is widely held that
it is due to an autosomal dominant gene.

Pathological changes: Circumscribed atrophic areas are seen in the
frontal and/or the temporal lobes. \Vhen the frontal lobe is involved
the changes are usually more marked in the frontal basal region, i.e,,
in the gjTus rectus, in Brodmann’s area II, and in the inferior frontal
convolution. Less commonly the convexity of the frontal lobe is most
affected, ^\^len the temporal lobe is affected the changes are found in
the pole and extend backwards to affect the whole of the middle and
inferior temporal convolutions, but only the anterior third of the
superior temporal convolution. In rare cases, where the parietal lobe
is affected, the changes arc found in the inferior parietal lobule. The
areas affected are all those regions of the brain which were the last to
develop phylogenetically. Microscopical examination reveals a gross
loss of cells in the three outer layers of the cortex of the affected area,

156 AN OUTtrWB OF FSTCItlATRT

which 5 a associated with a cortical and subcortical gliosis. The re-
maining cells show the characteristic degenerative change, in which
the cell enlarges, becomes rounded, and the cytoplasm becomes
homogenous. Globular atgyrophilic masses are also seen in the de-
generating nerve-cells.

Psychiatric clinical picture: The usual signs of dementia appear, but
as the morbid process affects the temporal and frontal lobes, the clinical
picture is usually coloured by a frontal or temporal lobe syndrome.
Social misbehaviour U often the first indication of the disease. Unlike
those suffering from Alzheimer’s disease, these patients are often silly
and facetious, with a careless indifference to their own mistakes. Spatiid
and temporal disorders are rare, but aphasia of a sensory nominal or
mi.ved type frequently occurs.

Neurological signs: Epileptic fits are less common than in Alzheimer’s
disease. Disorders of gait are rare.

Course of the illness: It may last from 2 to 15 years, or even longer.

c. Rare Varieties of Presentle Dementia. — Kraepelin desenbed a
rapidly developing dementia occurring in the fourth decade and after,
in which incoherent excitement, restlessness, negativism, delusions,
and hallucinations were present. Stem descril^d a presence dementia
associated with thalamic degeneration. Other obscure unclassifiable
presenlle dementias also occur.

2. Degenerations in which Neurological and Psychiatric
Symptoms are of Equal Importance.—

a. Huntington’s Chorea. — This is inherited as an autosomal Men-
delian doimnant, so that it usually occurs in half the offspring of a
patient. It may appear to miss a generation if the affected parent docs
not live long enough to develop the disease. The disease occurs in all
races. The incidence is about 5 per 100,000 in Britain.

Pathological findings: There is generalized atrophy of the brain with
enlargement of the ventricles. There is a marked loss of cells in the
third, fifth, and sixth layers of the cortex, and a loss of nerve-cells,
especially the small ones, in the caudate nucleus and the putamen.
The red nucleus, the substantia nigra, the thalamus, and the cerebellum
may also be affected.

The clinical picture: Tlus is a slowly progressive dementia associated
with jerky movements. The premorbid personality is usually abnormal.
Depression, paranoid states, unpleasant psychopathic behaviour, and
atypical psychoses may precede obvious signs of dementia for some
years. The illness becomes obvious about the age of jy years, but can
begin in the sixth or seventh decade. It has been seen in early child-
hood. The signs of dementia appear slowly and the patient gradually
becomes intellectually incompetent. In some cases the patient may be

PSYCHIATRIC ORGANIC STATES: SPECIFIC I57

able to live in the community for many years. Suicide and suicidal
attempts are common in all stages of the illness, even when the dementia
is profound. The involuntary movements develop insidiously and
usually appear first in the face and upper limbs and are always more
obvious there. The movements con^t of abrupt stretching and
jerking, which are irregular and uncoordinated, and most marked in
the proximal parts of the limbs. The face and trunk are affected by
writhing movements. Repeated sniffing movements are common. At
first the movements are not obviously choreic and the patient gives
the impression of being somewhat clumsy and fidgety. \Vhen the
movements become more marked the patient may disguise them by
turning them into voluntary movements. Thus a jerk of the arm may
be turned into a movement of smoothing down the hair.

Unusual clinical pictures' Occasionally depressive, paranoid, and
paraphrenic clinical pictures occur. Sometimes the dementia is not
accompamed by choreic movements, while some patients have nunimal
or no psychiatric symptoms.

Course of the illness: It usually lasts from lo to 15 years and the
patient dies before the age of 60 years.

4 . fakdb Creutsfeldt Disease ((^rtico-striato-spinal degeneration). —
This is a rapidly developing dementia associated with extrapyromidal
disorders and sometimes with lower motor neuron disorders. Ataxia,
dysarthria, spasticity, choreo*athetoid movements, tremor, cogwheel
rigidity, and muscular wasting occur. Death occurs within 6 months
to 2 years of the onset.

e. Hepatolenticular Degeneration (Wilson’s disease). — This disease is
the result of a biochemical defect which is usually considered to be
inherited as a Mendelian recessive. The basic disorder is the failure of
the alpha-globulin fraction of the plasma proteins to combine with the
copper absorbed from the intestine. The copper becomes loosely
attached to the plasma albumin and is taken up by the proteins in the
brain and the liver. This excessive deposition of copper leads to wide-
spread degeneration of the celb in the brain and the liver. The changes
are most marked in the putamen and in the caudate nucleus. The liver
becomes cirrhosed. There is also an increase in the urinary excretion of
amino-adds, but the origin of this anomaly is not known.

Clinical features: The first symptom is usually tremor and the illness
tends to begin in the second decade. Muscular rigidity soon develops so
that voluntary movements are impaired. Dysarthria and djspba^a
frequently occur fairly early in the course of the illness. The fades may
be Parkinsonian or there may be a silly vacuous smile. A diagnostic
feature which is not alwaj'S present is the Kayser-FIeischer ring of
golden-brown pigmentation of the cornea near the limbus.

158 AN OUTLINE OF PSYCHIATRY

Psychiatric clinical picture: A mild dementia which progresses very
slowly is the common psychiatric picture, but depression, mania, and
even clinical pictures resembling paranoid schizophrenia are occasion-
ally seen. Emotional lability and general loss of interest occur early in the
illness. A little later these symptoms may alternate with periods of
euphoria.

Course of the illness: If untreated, death commonly occurs %rithin one
to six years after the onset, although at least one patient survived for
thirty years. The progress ofthe disease can be arrested byadmlnistering
chelating agents such as penicillamine in doses of eight to ten 150-rag.
capsules per day.

3. Degenerations in vrhlcli Neurological Signs are out-
standing, but which can be associated with Dementia. — ^These
are numerous and include such conrUtlons as motor neuron disease
and the cerebellar degenerations.

PSYCHIATRIC SYMPTOMS IN CEREBRAL NEOPLASMS

Walthcr-Buel (1951) found that 70 per cent of a series of 600 patients
with brain tumours had psj'chological disorders. These could be
classified as: (t) Clouding of consciousness, 38 per cent of patients
showing psychological symptoms; (a) The amnestic syndrome, 38 per
cent; (3) Symptomatic epilepsy with psychological S)'mptoms, 12 per
cent; (4) Hypersomnia, 2*3 per cent; (5) Functional psychiatric syn-
dromes, such as schizophrenia, mania, depression, and neuroses, 4-5
per cent; (6) Combinations of groups (i), (2), {3); these combinations
seemed characteristic of cerebri tumours.

Walther-Duel found that, on the whole, the psychiatric symptoms in
brrin tumours were of an e-xpression of general disturbances of brain
function. Hypersomnia, uncinate fits, and the frontal lobe syndrome
were of localizing value, but this concerned only 5*5 per cent of the
whole series.

PSYCHOLOGICAL ILLNESSES CONNECTED IVITH
CHILDBEARING

Pregnancy.—

Normal Pregnancy . — Irritability and emotional lability often occur
in the first three months. Morning sickness occurs during this period
and has a physiological basis. After the third month most women have
a sense of well-being; in fact, some inadequate neurotic WTimen insist
that they feel well only during pregnancy.

Hyperemesis Gravidarum . — •Tliis is a hysterical exaggeration of normal
morning sickness. It occurs in immature hysterical personalities who
are unconsciously, if not coaaaoialy, rejecting motherhood. The

PSYCHIATRIC ORGANIC STATES: SPECIFIC

'159

treatment consists of psychotherapy and the administration of pheno'
thiazines, such as perphenazine, 2-4 mg. tliree times a day. The drug
may have to be given intramusailarly at first.

Neurotic and Psychogenic Reactions. — In general, typical depressions
(autonomous dysthymias) are rare during pregnancy and most depres-
sions during this time are psychogenic reactions of abnormal person-
alities to stress. Many unmarried pr^nant women are unhappy,
distressed, and threaten suicide. It is difficult to assess the seriousness
of such threats. Depression (autonomous dysthymia) can be treated w ith
electroconvulsive therapy during pregnancy without undue risk to
mother or child. Modified insulin therapy should not be given during
pregnancy. The anti-depressant drugs appear to be without risk in
pregnancy.

ThePuerperium. — The puerperal psychoses are not a unitary group,
but are constitutionally determined responses to physical and psycho-
logical stress.

Organic Stales. — Many women arc emotionally labile, irritable, and
somewhat anxious during the first few weeks of the puerperium. If
labour has been prolonged and much sleep has been lost a transitory
confusional state with auditory hallucinations may be seen. Delirium
and subacute delirious states are less common since the introduction of
the antibiotics.

>I^ee/trePrye/torer.— Depression (autonomous dysthymia) is the com-
monest psychosis in the puerperium. If it begins soon after childbirth
the clinic^ picture may be rendered somewhat atypical by a mild
confusional element. If the depressive features arc well marked in a
puerperal psychosis the diagnosis of schizophrenia should not be made
unless there are symptoms of the first rmk [see p. 134). Puerperal
depression responds to electroconvulsive therapy and the anti-depressive
drugs, such as inupmmine, phenelzine, and amitriptj’line.

Schizophrenia. — This does occur in the puerperium, but is not as
common as depression.

MENTAL DISORDERS OF OLD AGE

Many different kinds of nervous illness occur after the age of 60
years. Since the number of old people in the Western world is increas-
ing steadily, mental disorders in old age are becoming more important
and therefore warrant separate treatment in a textbook.

The Psychology of Ageing. — Pracdcallf every psychofogicai func-
tion increases in efficiency in childhood and adolescence until it reaches
its maximum value somewhere between 15 and 20 years of age, de-
pending on the function and the methods of measurement. After this
there is a slow decline which is usually unequivocal by the age of 35

l6o AN OUTLINE OF PSYCHIATRY

years. This applies to such functions as intelligence, motor speed,
reaclion time, and immediate memory. This decline of intelligence is
compensated in the third, fourth, and fifth decades by increasing emo-
tiond stability and knowledge. Hotsever, by the seventh and eighth
decades the decline in intelligence is obvious, especially in the dullard.
Personality traits tend to be enhanced by ageing. The only personality
change which is aln'ays associated with ageing is rigidity, which increases
steadilywith age.

The Size of the Problem. — The number of old people in the
population of Great Britain is increasing. Thus i2'6 per cent of the
population of England and Wales were of pensionable age in 1944, but
with current population trends 19*1 per cent of the population will be
of pensionable age in 1984. In 1937 the first-attack admission rate to
mental hospitals for elderly patients in Er^gland and Wales was, for the
age-group 55-64 years, 75 per 100,000 for males, and 79 per 100,000
for femaJea. For the age-group 65 -f- the rate was 79 per 100,000
for males, and 77 per rco,ooo for females. The admission rates for
New York State are considerably higher than the English admission
rates and show a marked excess of males over females. This difference
is partly due to the admission of Eoglish psychiatric patients to social
welfare and chronic sick instinirions, and partly due to social factors,
The admission rate of old people to mental hospitals probably varies
inversely with the degree to which the aged are protected agdnst
insecurity by pensions and other benefits.

Classification of Mental Disorder in the Aged. — Eighty
years ago Thomas Clouston (1B83) pointed out that about one-third
of the old people admitted to his mental hospital were subsequently
discharged. A little later Kraepelin (1896) asserted that the majority
of mental disorders of old age were depressive states. In Germany
and the United States this fact was forgotten and severe mental dis-
orders in old age were considered to be due to dementia, which might
be present with deprcssivic or paranoid features. More recently Roth
(1955) has claimed that he was able to classify all but 14 of 464 senile
patients admitted to a mental hospital into five groups. These were:
(i) AfFective psychoses; (a) Senile psychosis; (3) Arteriosclerotic psy-
chosis; (4) Delirious states; (5) Late paraphrenia.

1. Affective Psychoses . — ^These were mainly depressive and accounted
for about half the cases. Only a few of these patients subsequently
became demented.

2. Senile Psychosis . — ^This is a (bmentia, but Roth decided not to
use the term ‘senile dementia’, because it had been claimed that there
was no correlation bctiscen the brain changes and the degree of the
dementia. This has subsequently been disproved, and this group will
be referred to here as ‘serule dernentia’.

PSYCHIATRIC ORGANIC STATES: SPECIFIC l6l

3. Arteriosclerotic Psychosis . — ^Thk is a dementia secondary to isch-
aemia of the brain produced by arteriosclerosis.

4. Delirious Slates . — These were rapidly developing states of clouded
consciousness with or without a detectable physical basis.

5. Late Paraphrenia . — Individuals suffering from this disorder had
fairly well systematized paranoid delusions and a well preserved
personality in the absence of coarse brain disease. More recently
Roth (1961) has claimed that these patients are really schizophrenic.
The present author believes that this is a group of heterogenous condi-
tions only some of which are schizophrenic. A better designation for
this group is 'senile paranoid state*.

Note: Although most \vorkers in this field would agree that Roth’s
five main groups include the majority of severe mental disorders in
old age, at least two other workers have found rather more unclassifi-
able cases than Roth. The differentiation of arteriosclerotic from senile
dementia is often not easy, and in many cases depends on the post-
mortem exarmnation rather than on the clinical findings.

Affective Psychosis. —

Aetiology . — Roth found that senile depressives, who broke down for
the first time after the age of 60 years, had more severe and more
chronic illness than those who had broken down before that age, but
the familial incidence of manic-depressive disease was the same in
both groups. He concluded that those patients who became depressed
for the first time over the age of 60 years had better personalities and
were breaking down because of the severe stress of physical illness.
Roth considered that bereavement, retirement, and loneliness were
only contributory factors of little significance.

Clinical Picture . —

Depression: Usually it is a typical agitated depression (autonomous
dysthymia), but sometimes there b a simple depression with retarda-
tion, slowing down of all activity, and a difficulty in making decisions.
Thb may lead the unwary to m^c a diagnosis of early senile dementia.
Some patients present with neurotic-like states displaying anxiety and
hypochondriasis.

Mania: These patients are hyperactive with flight of ideas. They
formed 5-10 per cent of Roth’s series.

Diagnosis . — In senile dementia, there is a history of many months of
poor memory, grasp, and orientation, while in arteriosclerotic dementia
lability oi affect and neurolopc^ signs tend to occur. In paranoid
states the delusions cannot be derived from the mood, and other symp-
toms, such as auditory hallucinations, are present {see p. i66). Clouding
of consciousness occurs in some depressions as a result of malnutrition
or concomitant physical disease. In such cases the symptoms of
depression have dearly preceded the douding of consciousness.

i 62 an outline of psychiatry

Treatment. — In-patient treatment will be required in most cases. A
thorough physical investigation, treatment of malnutrition, and careful
investigation of social background tvill be necessary.

Electroconvulsive therapy. This may be advisable if there is no
response to anti-depressants or if the patient is severely depressed, with
agitation, leading to exhaustion or feeding diiliculdes. Risks must be
t^en in the presence of ph^ical illness, since the depression can kill
from suicide or intercurrent infection.

Drugs: Imipramine 6o mg. per 24 hours. Side-eiTects due to this drug
are much more frequent in elderly patients. Monoamine oxidase
inhibitors are useful in mild cases of depression {tee p. 124).

Mania: The treatment of mania is described on p. 125.

Leucotomy: This may be required in recurrent depressions or in
long-standing depression with transitory response to E.C.T. (seep. 212).

Senile Dementia. —

Aetiology . — -A hereditary factor is probable, but not proven. Brain
changes are always present.

Morbid Anatomy . — Signs of atrophy of the brain are usually risible
macroscopicalty. Microscopically there is diffuse outfall of nerve-cells,
but the cytoarchitecture is fairiy well prese/red. Neurona show
shrinkage and chromatoiysis. There is some macro- and microglial
proliferation. Senile plaques and neurofibrillary changes are usually
present, but these may be absent. Anterior frontal areas are usually
severely affected, and the motor area and the cortex posterior to it are
less affected. Plaques and neurofibrillary changes may occur in the
periventricular grey matter of the third ventricle, in basal ganglia, and
in the thalamus.

The Psychiatric Clinical Picture . —

Age and sex: Patients are usually over 70 years of age, and there is
an excess of females.

Onset: There is a gradual onset, but the disorder advances rapidly.

Memory.Tbia is the first intellectual function to be noticeably affected.
Recent memory fails, but memory for remote events is apparently intact.

Blunting of emotion: This leads to petulant and irritable behaviour;
finally to apathy or childish euphoria. Depression, with e.xtrav3gant
delusions of guilt, and depravity, may occur. Usually the mood is
shallow and transient. Mood changes of this kind are more common in
arteriosclerotic psychoses.

Intellectual defects: The padent tires easily and cannot follow the
argiiment. Jlo may get over difficulties for a time by rigid adbercncc
to a routine. Sloxvncss and perseveration are evident, and the indivi-
dual becomes muddled with the amplest tasks. Speech deteriorates.
At first it is verbose and repetitive, with stereotyped phrases, and the

PSYCHIATRIC ORGANIC STATES: SPECIFIC 163

tmn of thought is easily lost, but finally it becomes a mere babble
of words. Delusions arise from lade of grasp, failure of orientation,
and inability to interpret the environment. Thus, mislaid articles
are alleged to be stolen and nurses are identified as the patient’s
children.

Sleep". This b often disturbed. The patient potters about the house
in the middle of the night and may wander about the streets.

Urinary incontinence". This occurs early. Faecal incontinence occurs
sooner or later.

Toilet and cleanlinesi". These habits arc faulty, and the patients will
not wash.

Acute delirium: This may be provoked by infecrion, a fracture, or a
sudden change in the envirorunent. There is severe restlessness, wth
auditory and visual hallucinations and paranoid ideas. The patient may
commit violent assaults or wander incessantly. The death-rate is high.
Recovery from the episode leaves the patient more demented than
before.

Outcome . — Most of these patients are in an advanced state of dementia
on admission to mental hospital and usually have a history of i-2|
years of illness. Sixty per cent are dead in six months and 8o per cent
are dead in two years following admission to mental hospital (Roth,
1955). Death is due to intercurrent infection or more usually to
vegetative extinction. The weight falls, all activity declines, blood-
pressure drops, and the temperature becomes subnormal.

Diagnotis. — Tumour, general paresis, arteriosclerotic psychosis, and
Abcheimer’s (fisease must be excluded.

In arteriosclerotic psychosis the course is more acute; the illness
renuts and fluctuates. Neurological signs and symptoms occur sooner
or later, and there is a preservation of personality until the late stages.

Alzheimer’s disease occurs in an earlier age-group; there is a dis-
crepancy between physical and mental ageing.

Treatment . — ^The patient should be kept at home unless his behaviour
becomes too difficult. He should be kept out of bed and given general
nursing care. Fhenothiazines may be given for restlessness, but only
small doses may be needed, as such patients are usually very sensitive
to these drugs.

Arteriosclerotic Psychosis. —

Aetiology . — It usually begins in the sixth decade, but occasionally in
the fifth, and hypertension is present in about half the cases. A severe
cerebrovascular accident ushers in half the cases.

Clinical Features . — ^The onset muy often be a delirious episode which
brings the patient to the doctor, but sometimes it is depression or a
suicidal attempt.

164 AN OUTLINE OF PSYCIJIATIiy

Vsythahgieal symptoms: Memory for recent events is impaired, but
may be relatively isolated, and the patient may compensate wth a note-
book. Occasionally there is a fidl-blossT) amnestic syndrome. The
intellectual functions are impaired; there is difficulty in concentration
and the patient is slow to grasp situations, especially new ones. Judge-
ment is relatively veil preserved. Until a late stage the patient has
insight into the change taking place in him. Emotion is often blunted
and interests arc diminished. The patients are often despondent and
pessimistic due to awareness of their own decline. Emotional in-
continence is characteristic. Depression is common, and sev'ere, per-
sistent, depressive mood changes occur in 5-10 per cent of cases;
usually depressions arc short-Iited and often in the setting of the
clouding of consdousness. Determined suicidal attempts occur in
delirious episodes, but the patient ma)’ be euphoric on admission to
hospital after the attempt.

Somatic Signs and Spmploms. — Headache, giddiness, tinnitus, and
chest pain arc common. Coronary artery disease is also common.

Neurological Signs and Symptoms. — These occur sooner or later.
Epileptic fits occur in 15-20 per cent of cases; usually generalized and
less often Jacksonian. Occadonally there is loss of consdousness, no
fit, but hemiplegia with recotery. Minor neurological abnormalities,
such as sluggish pupils, unequd tendon jerks, and extensor plantar
responses, arc often seen. IVkinsonism occurs in a small proportion
of eases.

Ctww.— Usually it is fluctuating with scute delirious episodes with
clouding of consdousness which may give the impression of severe
dementia. Recovery from these episodes occurs in daja or weeks, but
residual impairment is detectable 3fter%vards. Social recovery is
common. Fluctuation in severity may occur from hour to hour; the
patient may be disorientated at one time, but ludd an hour or two later.
Clouding of consdousness is often more severe at night. Finally the
patient becomes fatuous, forgetful, and develops faulty toilet habits,
but even so some shell of the personality may remain. Death usually
ensues from cerebrovascular acddent,poeumonis, or heart failure.

Prognosis. — In Roth's series, six months after admission one-third
were dead, one-quarter discharged, aod the rest were in-patients. After
two years 70 per cent were dead. These are mental hospital figures
and may not reflect the true outcome.

Diagnosis. — Cerebral tumour, general paresis, and prcsenile dementia
must be excluded. Subdural haematomashould be considered(mp. 153).

Differentiation from senile dementia : —

In arteriosclerotic dementia the following features are distinctive: —

I. Signs of a cerebrovascular lesion.

PSYCHIATRIC ORGANIC STATES : SPECIFIC 165

2. A markedly fluctuating or remitting course.

3. Preservation of insight and personality until a relatively late stage.

4. Explosiveness or incontinence of emotional expression.

5. Epileptic fits.

Treatment . — ^Patients should remain at home where possible, and
should be kept active. If the depression is severe electroconvukive
therapy can be given, or an antidepressant drug. These measures must
be used cautiously since they can increase the degree of confusion.

Delirious States. —

Aetiology . — Roth found that in 50 per cent of delirious patients
there were acute infections, the commonest being pneumonia and acute
bronchitis. He also found that the illness followed major operations,
especially prostatectomy and cataract extraction. However, in 30-40 per
cent of his cases Roth could find no specific cause and assumed that a
toxic factor or vitamin deficiency was Ae cause. In a series of 93 senile
patients admitted to a delirium unit Williamson and Fish found that
9 were misdiagnosed depresstves and i was a senile paranoid state. Of
the remainder, 38 were suffering from arteriosclerotic and/or senile
dementia, ta had cardiac failure which was frequently the result of a
recent cardiac infarct, and lo suffered from respiratory or urinary tract
infection. The remaining patients suffered from miscellaneous condi-
tions such as primary or secondary cerebral neoplasms, fat embolism,
head injuiy, and so on. In 6 patients barbiturates appeared to have
played an Imporunt part in the causation of the delirium. The tendency
of the aged to become confused even on small doses of the quick-acting
barbiturates is not sufficiently appredated.

Clinical Features . — The patient will have been mentally well until
recently, and looks well preserved. The rapport, despite clouding of
consciousness, is surprisingly good for short intervals except in severe
cases. Marked fluctuations in the level of awareness are very character-
istic. These patients pve fairly elaborate, positive, wrong answers,
whereas advanced arteriosderotic patients and senile dements give
vague answers or deny all knowledge. There is a richness in the
content of thought as compared with the well-established dement.
Inconsistent orientation is fairly common, so that two incompatible
orientations may occur side by side.

Diagnosis . — Delirium in asenile dementia is characterized by content-
less hyperactivity and incoherent exdtement. Delirium in arterio-
sclerotic dementia may be difficult to distinguish in the early stages
of the disease. The appearance of neurological signs and duration for
months or weeks may decide in fn'our of arteriosclerotic dementia.
On the whole the presence of clouding of consciousness excludes the
functional psychoses, but a mania, depression, or a paranoid state may

l66 AN OUTLINE OP PSYCntATnY

be complicated by a delirium produced by malnutrition or intercurrent
disease.

Treatment. — TJie underlying infection should be treated if possible,
and antibiotics should be given if the patient is febrile or very III.
Parentrovite may be administered ($ee p. 104).

Senile Foranold Slate (late paraphrenia). —

Aetiology, — One-quarter have some defect of sight or hearing.
Females predominate, and patients ate usually isolated individuals
living on their own (Rnth). Some are probably cases of schirophrenia.

Clinical Fealiirei, — Florid persecutory delusions arc alwa)'8 present;
the patient complains of being gassed and raped; people arc alleged to
enter the house and interfere. Hallucinations occur, which may be
voices, noises, odours, and lights. There is normal orientation and
good contact Viith surroundings. No deterioration in toilet habits
occurs. Judgement and reason arc well preserved outside the delusions.
Sometimes delusions of poisoning lead to malnutrition and a con-
fusional state.

Diagnosu. — Senile psychosis, artcriosleroiic dementia, delirious
states, and depression should be difrerentiated.

Senile dementia: Loosely connected and ill-systematized persecutory
delusions occur in this condition.

Arteriosclerotie dementia: Persecutory delusions are occasionally
closely knit, but they tend to fluctuate. Dementia is usually obvious
and neurological signs may be present.

Deliriout tlatet: Oouding of consciousness occurs.

Depression: Some depressives have delusions of persecution, wbicb
they consider to be unjustified. If there arc no oilier non-understand-
able symptoms the illness should not be called schizophrenic.

rrognoiif. — Roth found that only 3 per cent were dead in six months
and 20 per cent within two years of admission. The mean age of these
patients was higher than that of the alTcclivc group; there is an unusual
longevity. Recos'ery before the introduction of phenothtazines was
rare. Only 20 per cent of Roth’s patients were out of hospital within
two years of their first admission.

Treatment. — By phenothiazines, for example, thioridazine (mclleril)
300-400 mg. In 24 hours (rre p. 197). Post (1962) has found that only
a few of these patients fail to respond satisfactorily to high doses of
phenothtazines.

i67

CHAPTER XIII
SEXUAL DISORDERS
GENERAL DISCUSSION

Classification. — Sexual disorders may be classified as follows: —

1 . Disorders of the inten^ty of sexual drive, for example, impotence,
frigidity, etc.

2. Disorders of the direction of sexual drive. —

a. Deviation of the aim of sexual satisfaction. These are the perver-
sions such as fellatio, anal intercourse, etc.

b. Deviation in the choice of sexual partner, for example, homo-
sexuality, bestiosexuality, and so on.

Note: The terms ‘perversion’ and ‘inversion’ are used in different
ways by different authorities. Thus, some refer to homosexuality as
‘inversion’, while others have called the completely feminine male
homosexual an ‘Invert’.

Normal Sexual Intercourse.--Tfais can be defined as ‘sexual
activity which has as its aim an orgasm in both partners, produced by
the aaivity of the penis in the vagina’. The sexual activity which
precedes the insertion of the penis is called ‘foreplay’. This can take
many forms, such as genital kissing, oral kissing, biting, and manual
stimulation of the penis, clitoris, or vagina. However, as long as the
foreplay is only preparatory to the insertion of the penis in the vagina,
it cannot be regarded as a sexual perversion.

Matussek has pointed out that the standard views on the parts played
by the male and the female in coitus are distorted by ideas carried over
from anatomy. For example, we compare the penis with the clitoris,
but the part played by these two structures in coitus is quite different.
Sexual intercourse begins with the man fondling the breasts and
fingering the introitus. This and other foreplay bring about a readiness
on the part of the woman for coitus. It also increases the man’s desire
and leads to an erection, which in turn excites the woman, who responds
with increased vaginal secretion. Thb increase in secretion stimulates
the man even more, reinforces his erection, and leads to insertion of the
penis. Coitus then follows and ends with the man ejaculating and the
woman having a vaginal orgasm. The weakest point in the man’s
sexual performance is the achievement and maintenance of an
erection, whereas the weakest point in the wroman’s coital activity is

the achievement of an orgasm. Thus the absence of orgasm in the
female is the commonest disorder of coitus, while in the male inability
to maintain an adequate erection is the most frequent disorder.

It is difficult to be sure of the average frequency of sexual inter-
course among married couples, but there is no doubt that it declines
with age. Coitus is probably carried out about three times a week
during the third decade and falls to twice a week in the fourth decade.
However, the ‘normal' frequency of coitus varies considerably in
different societies. Many men have oven'alued ideas about the ‘normal’
frequency of coitus.

DISORDERS OF THE INTENSITV OP SEXUAL DRIVE

Impotence. — 'Phis is the failure of a man to have a satisfactory
orgasm with his penis within the vagina.

Varieiiti of /m/io/ewfe.— These may be summarized as follows: —

1. Complete absence of any se.\iial desire.

3. Sexual desire is present, noclumal emissions and spontaneous
erections occur, but a female partner cannot produce an erection.

3. Erection occurs, and coitus is possible with some women, but
not with others.

4. Coitus is possible with any woman from time to time but not
consistently.

5. Ejaculatio praecox. Ejaculation occurs before or at the moment
of contact of the penis with the introitus or immediately after insertion.

6. Ejaculatio retardata. The penis is inserted into the vagina and
coitus takes place, but ejaculation does not occur.

Physical Causes. — Endocrine disorders and neurological diseases
account for only 10 per cent of all cases of impotence.

Psychological Causes. — The foJJoiving psychological conditions may
be responsible: —

1. Psychiatric Depression (autonomous dysthymia) may

produce impotence. Severe anxiety from any cause will also do this.

2. The effect of the immediate situation: Attempts at coitus in situa-
tions in which there is a possibility of discovery may fail, because the
anxiety is sufficient to interfere with an erection. Fear of venereal
disease or disgust make some men impotent with prostitutes or with
Very promiscuous women.

3. Psychological exhaustion: Overvalued ideas about coitus may lead
Some men to insist on sexual intercourse two or three times a day or
even more. Physiological exhaustion leads to difficulty in achieving
aod maintaining an erection.

4. The Koman: A wife may express her antipathy to sexual inter-
course by being rampletely passive, permitting penetration, but

SEXUAL DISORDERS

169

refusing to stimulate the husband in any way. The lack of emotional
response and the lack of phyuological response, in the form of in-
creased vaginal secretion, diminish the husband’s desire. Impotence
occurs and the \vife blames the husband and laughs at him. The
repeated failure and the wife’s scornful attitude convince the man of
his impotence. Thus the basically frigid wife avoids coitus and is
able to blame her husband for the lack of something which she does
not want. This is really a 'double bind’ technique (see p. 127). Some
wi\ es, who are basically frigid, use their ability to allow or refuse coitus
in order to control their husbands. The husband may be disgusted by
this behaviour and become impotent because of the lack of genuine
feeling on the part of his wife.

5. Unconsdous psychological causes: Often the cause of the impotence
is to be found in unconscious attitudes due to childhood difficulties.
It has been suggested that severe unconscious castration anxiety may
cause impotence, because the man regards the vagina as a castrating
mechanism. Latent homosexuality, which is related to castration
anxiety (see p. 26), also plays a part in some cases. Sometimes the
partner is identified Nvith the ‘pure’ sister or mother, so that the
impotence is a reaction formation produced by incest wishes. Often
unconscious antipathy towards coitus can be found in both partners.

6. The vicious circle: Erection is a sign of manhood, so that failure
to achieve an erection and have intercourse produces a sense of shame
and marked anxiety. The next attempt at coitus is, therefore, ap-
proached with fear. This leads to a poor erection and failure to have
coitus. This vicious circle of impotence — anxiety, further impotence,
more anxiety — is very difficult to break.

Treatment . — Although endocrine diseases are not very common
causes of impotence, most patients with impotence are given testo-
sterone before they are referred to a psychiatrist.

The circumstances in which impotence occurs must be carefully
investigated by interviewing both the husband and the wife. The
%vife’s attitude to sexual intercourse must be assessed. The patient
should be told not to attempt coitus during the first few weeks of
psychotherapy. If the causes of the impotence appear to be fairly
superficial, the patient should be told to attempt sexual intercourse
when he feels like it. If possible he should take a small dose of sedative,
for example, meprobamate 200 mg., or amylobarbitone sodium 65 mg.,
half an hour before coitus. The reduction of anxiety produced by the
sedative may permit satisfactory intercourse. This treatment is particu-
larly useful in patients with premature ejaculation. If these measures
fail, psychotherapy should be continued and sexual intercourse should
not be attempted again for a few weelu. Penile splints which allow the

170 AN OUTLINE OF PSYCHIATRY

insertion of a flacdd penis have been used. It is claimed that coital
activity with a splinted penis leads to an erection and an orgasm. This
is not 3 very satisfactory form of treatment.

Satyriasis. — Some men haw an almost insatiable sexual desire
which they satisfy by frequent intra- and extramarital intercourse
and masturbation. Usually these individuals do not ask for treatment.
Some anxious depressives have an increase in sexual desire and may
obtain temporary relief of anricty from coitus or masturbation.

Priapism. — ^This is a painful penile erection in the absence of
sexual desire. It lasts for days and is usually associated with dysuria.
The corpora cavernosa are engorged, but the corpus spongiosum and
glans are not. It is often caused by diseases of the central nervous
system and blood disorders. In about 25 per cent of cases it is due to
leukaemia. Occasionally sudden interruption of coitus just before
ejaculation produces priapism. If the condition is not due to disease
of the central nervous sj-stem the corpora cavernosa should be aspirated
with a wide-bore needle and washed out with normal saline.
Frigidity.—

General Problem }. — Frigidity is the absence of an orgasm in the
female during sexual intercourse. It U more common than impotence,
since the female has much more diiliculty in achieving an orgasm than
the male. The woman’s first experienws of coitus are often painful and
disappointing. Later, coitus is often unsatisfactory because the man
does not indulge in sufiicient foreplay and ejaculates somewhat prema-
turely. Thus the %toman is not likely to have an orgasm until she has
had some praaice with a competent partner. 'While many men can
have sexual intercourse vrith almost any woman, many women need to
feel loved and wanted apart from the sex act. If such women feel that
their partner is only using them for physical satisfaction, their enjo}'ment
of Coitus is diminished and they do not have an orgasm.

Varieties 0/ Frigidity . — Four varieties of frigidity may occur. These
arc: —

I. Total frigidity: The woman has no sexual desire, cannot be
aroused sexually, and is nauseated by the idea of coitus. The most
extreme form of total frigidity is vaginismus, in which any attempt at
0}itu3 produces spasm of the adductors of the thighs and arching of
the back, associated with marked amue^.

1. Vagina! kypo-aesthesia: The sroman has sexual desire which
increases with love play, but the increase in vaginal secretion is not
great. Sexual excitement is present at the beginning of coitus, but
dies aw:^ before the man ejaculates. The more frigid the woman the
more quickly does the sexual excitement disappear after the insertion
of the penis.

SEXUAL DISORDERS

I7I

3. Vaginal hypo-aesthesia tcith ditoral sensitivity: In these women
sexual excitement occurs during love play, but the vagina is relatively
insensitive, so that only a ditoral orgasm is experienced.

4. Nymphomaniac frigidity: The woman has intense sexual sensations
during intercourse but no o^asm. This lack of a satisfactory orgasm
gives rise to an insatiable desire for coitus. This is an arm-chair theory,
since many so-called nymphomaniao have orgasms during intercourse
but are unable to make permanent emotional relationships with men.

Physical Carnes. — Disorders of the endocrine glands and the nervous
system can cause frigidity.

Psychological Causes. — ^The following psychological causes may be
responsible: —

1. Psychiatric illnesses: Depression (autonomous dysthymia) is often
associated with a decrease in sexual desire and a dislike of sexual inter-
course. This may lead to disagreements with the husband and enhance
the feelings of guilt.

2. The effects of the immediate situation: Anxiety from any cause may
produce frigidity. Sexual intercourse in drcumstances in which it is
likely to be interrupted, fear of pregnancy, domestic difficulties, bad
news, and so forth can all lead to frigidly.

3. Preconceived ideas: Some women are brought up to believe that
coitus is a wife’s painful duty, which must be tolerated, but cannot be
enjoyed. Such an attitude may be reinforced by an inconsiderate
husband who makes no attempt to stimulate his wile.

4. The man: If the husband fails to arouse bis wife and ejaculates
soon after insertion of the penis, the wife will be disappointed. This
will enhance any antipathy towards intercourse, so that even if the
husband’s performance improves it is still not adequate to bring about
an orgasm.

5. Unconscious causes: It has been claimed that oral fixation may
produce frigidity, because frustration at this level may lead to the
woman being unable to accept gifts and in particular to accept the gift
of the penis. Anal fixation may also produce frigidity. It has also been
suggested that penis envy may produce frigidity, which can be regarded
as an attempt to ret^n the penis. Abraham suggested that vaginismus
expressed an unconscious wish to break off and retain the penis.

Treatment. — A careful investigation of the coital technique and the
circumstances in which it is performed must be made and any faults
discussed. The Vra^and may need a sedadve to prevent premature
ejaculation. The patient’s attitudes to sex must be carefully explored
and any false ideas corrected. If these simple measures fail, more
intensive psychotherapy is necessary. Marked aversion to sexual
intercourse, in particular vaginismus, is very difficult to treat.

J72 AN OUTLINE OP PSYCHIATRY

Nymphomania. — In Western sodety quite a number of men have
3 tveli-markcd sexual drive which th^ are able to sitlsfy with almost
any woman. Although such men are not usually considered to be
abnormal, it is usual to regard ntunen with similar sexual habits as
abnonnal and call them nymphomaniacs. Psychoanalytic wTiters have
suggested that these women have over-identified m’th their fathers and
therefore take an active role in sexual behariour. They pass from one
man to another in a fruitless search for a father surrogate and their
excessive sexual drive is a reflection of marked unconscious incest
wishes.

Some hypomanic women become very promiscuous and in a
state of careless abandon may become pregnant or acquire venereal
disease.

AETIOLOGY OF THE DISORDERS OF SEXUAL DRIVE

Constitutional Theories. — It has often been claimed that
per\'ersions are inborn, but there is no good evidence to support
this view.

Psychoanalytic Theories. — In the perversions the Oedipal con-
flict is not resolved, so that the castration anxiety leads to the choice
of a sexual object which disguises the incest fantasies and allows
sexual satisfaction. Nacht has suggested that the pervert has such
intense aggressive and libidinal drives that the ego has to put a safe
distance between itself and the object which is both unconsciously
desired and feared. This leads to the formation of a defence mechanism
which is completely eroticized. Activation of this defence mechanism
brings about an orgasm. Sometimes this activation produces severe
anxiety and this leads to an orgasm. The eroticized defence mechanism
is derived from earlier pregenital libidinal fixations. The ego is unable
to make a genital investment of the object, which is feared and for-
bidden. This direct erotieszation of the defences leads to marked
therapeutic difiiculties, since the symptom is not only the solution of
a conflict but is also a conscious source of sexual satisfaction. This is
in contrast to the neurotic symptom which does not produce direct
satisfaction although it may result in considerable secondary gain.

Ethological Theories . — It is tempting to compare the deriau'ons of
sexual drive with the deviations of other drives which ha%'e been pro-
duced in experimental animals (see p. 5). Perverts often claim that
some specific experience in childhood probably caused their perx-er-
sfon. ffowever, simf^ experiences occur in persons tsho do not
become perverts. There is, of course, little doubt that exposure to
repeated perverse practices in childhood or adolescence will produce
a pen’crt.

SEXUAL DISORDERS

173

CLINICAL FEATURES OF DEVIATION OF AIM
(PERVERSIONS)

Often the opposite type of perversion occurs in association with a
given perversion. Thus voyeurism and exhibitionism, for example, may
occur in the same individual. Apart from this many different perversions
may occur in the same individual.

Sadism (Active Algolagnia). — ^The pervert obtains sexual enjoy-
ment from the suffering of others. The term ‘sadism’ is now used in
a wider sense of enjoyment of the suffering of others without any frank
sexual element. Usually the degree of suffering inflicted is limited,
but the sight of blood may be necessary to produce an orgasm. The
punishment may be carried out with whips, canes, backs of hair-
brushes, or the bare hands. Usually the sadist likes beating the but-
tocks, but the genitalia or the whole body may be beaten. Other per-
verts enjoy biting the sexual object. Sometimes the sadistic practices
take the form of play-acting in which the victim is chained, bound with
ropes, humiliated, and degraded in some way. Other sadists enjoy
tvatching sadistic practices, or, in other words, they are voyeurs and
sadists. The scxud object may be of the same sex, the opposite sex, a
child, or an animal. In general, males are more often sadistic and
females masochistic. Thus two perverts may make a harmonious
heterosexual sadomasochistic relationship. A few sadists obtain sexual
satisfaction from violent murder and mutilation of the sexual object.

Masochism (Passive Algolagnia). — In this perversion sexual
enjoyment results from pain and humiliation. Usu^ly these perverts
do not like to feel a lot of pain. However, some of them do have
fantasies of being killed. Often the pain is only used to produce sexual
excitement prior to vaginal or anal intercourse. Some patients need
to be tied up or chained, while others need to be humiliated. Some-
times orgasm is achieved by being defaecated upon or urinated on by
someone else. This may be carried out by the partner defaecating on a
glass table trith the subject lying underneath. ‘The horse of love’ is a
complicated masochistic practice in which the pervert gets his enjoy-
ment from being ridden like a horse. A saddle is strapped on the back
and the partner wears boots and spurs and mounts the subject as if
he were a horse.

Associated perversions may be present. There may be some ele-
ments of fetishism. The partner may be obliged to dress in shoes,
boots, or furs while he or she beats the patient. Some male masochists
like to be trodden on by a woman wearing high-heeled shoes. Oral
perversions may be combined with masochistic practices so that the
subject may lick his partner’s feet or anus or may persuade his partner
to micturate or defaecate Into his mouth.

174 an outline of psychiatry

Psychological Thoorics of the Oiigtn of SadomasocUsm.—
In young animals and children there is a primary erogenous masochism,
since they appear to enjoy marlced excitation, ■which leads to some dis-
comfort and pdn, so long as the pain is not too severe. Masochism
could, therefore, be regarded as a prcser\-ation and elaboration of this
‘ primary masochism’. Witnessing and experiencing brutality in child-
hood is likely to produce sadomasochism.

Originally Freud explained sadism as being derived from the
agressivc features of the libido and masochism as the turning back of
the aggression on to the subject Later, when he introduced the concept
of Tkanatot or the death instinct, he suggested that in sadism the death
instinct is eroticized by the libido. \\'hcn it is externalized it produces
sadistic behaviour, but when turned back on the self it produces
masochism.

Sadism can be regarded as a defence against severe castration anxiety.
The subject resolves the Ocdipal conflict by symbolic castration. He
acts on the basis of the formulation, * I am not castrated. I am the
castrator.' Masochism can also be regarded as a defence against
castration anxiety. Thus it may represent castration eymbolically or
the subject may feel that by organizing a systematic torture uhJch he
can tolerate he is defending himself against something ^\orse.

Voyeurism (Scoptophilia). — In this perversion the individual
obtains sexual enjoymeot from watching naked men, naked women,
naked children, normal or perverse sexual acts, or excretory acts. Some-
times the subject watches himself having sexual intercourse in a mirror.

Psychological Theories . — ^The child secs the mother and embraces
her mth his look. Since the mother frequently satisfles the child with
food and affection, then seeing the mother is associated with pleasure.
In this way the act of looking becomes libidinallzed. Since many
mothers arc seen by their young sons in varying states of nudity it
would appear that this behaviour is not the major cause of voyeurism.
This perversion has been explained as a defence against castration
anxiety. The sight of the female genitalia or sexual intercourse during
the Ocdipal stage of Ubidinai development accentuates the castration
anxiety. The subject seeks to witness repetitions of the oripnal
frightening scenes in order to reassure himself that castration has not
occurred.

Exhibitionism. —

Sympiamalie Exhibithnism . — Some epilepliCT, manics, schizo-
phrenics, and mental defectives exlubit their genitalia.

Clinical Features . — This perversion is confined to males although a
few females exhibit their breasts. Most of these perverts are mild
timid men who are married and have a fairly reasonable sex life. The

SEXUAL DISORDERS

175

pervert chooses a public place which is not too welt frequented, and
shows his penis to one or two women, gifls> or, rarely, boys. A few of
these subjects exhibit their buttocks. When the penis is demonstrated
it may be flaccid or erect and the pervert may masturbate or even
ejaculate in front of the victim.

Some authorities have divided exhibitionists into impulsive neurotic
and perverse types. The former is not very common. These patients
have depression and anxiety assodated with an uncontrollable desire
to exhibit the penis. Finally, after an unsuccessful struggle to control
the impulse they exhibit a flacdd penis and the anxious depressed
mood disappears.

The perverse exhibitionist enjoys the act and exhibits an erect penis
while masturbating and, if possible, ejaculating in the presence of his
victim. For pleasure to be complete the victim should react dolently
to the act with shock, fear, interest, or even pleasure. This type of
pervert takes great care not to be caught. The penis is often out of the
trousers underneath a buttoned-up coat, which can be quickly undone
in a suitable situation. The two types are really the extreme ends of
a continuum.

Psychoanalytic Vieas . — The perversion is regarded as a defence
against castration anxiety. Thus by demonstrating his penis the
subject is reassured that he is not castrated. The fear of the victim
proves to him that he has power over others and therefore has no
need to be frightened of anyone. Finally, it may be the expression of
a wish to see a girl with a penis in order to assuage his castration
anxiety. It is as if he is saying to his victim, ' I am showing you what
I would like you to show me’.

Other Perversions of the Sexual Aim. — Many other perversions
occur and are often worked into elaborate routines with those already
described. Thus there are oral perverrions in which sexual satisfaction
is obtained by licking, sucking, biting, or ingesting the object. Similarly
there are anal and urethral perversions.

DEVIATIONS IN THE CHOICE OF SEXUAL PARTNER

Paedophilia. — Here the pervert chooses a child as a sexual partner.
Some mental defectives do this because their low intelligence leads
them to select a partner with a similar intelligence, and also because
of their lack of appreciation of the seriousness of the situation. The
true pervert seems to identify with the child and treats it in the same
%vay as he would like to have been treated at that age, so that this
perversion appears to have a narcissistic basis. Occasionally the object
is of the opposite sex but usually it is of the same sex. Various kinds
of sexual activity may take place with the victim.

176 AN OUTLINE OF PSYCHIATRY

GerootopMUa. — These patients need an elderly sexual partner,
and this can be regarded as a displacenicnt of incestuous ^sishes. Occa-
sionally adolescents between the ages of 14 and 20 years make aggres-
sive attacks on elderly women with a view to rape or with no o^ous
purpose.

Erotic Zoophilia (Bestiality). — ^Tlicse perverts use an animal as
a sexual object. Tliis is partly determined by the environment. Thus
Kinsey foimd that whereas only 8 per cent of the men in his
sample had had sexual relations with an animal, no less than 50 per
cent of those brought up on farms had had such relations. It often
occurs in mental defectives fame de mitux. Sometimes it appears that
the pervert chooses an animal as a sexual object because he knoirs that
it cannot dominate him. Some voyeurs prefer to observe zoophilic
sexual behaviour and brothels cater for this by staging exhibitions of
this kind.

Necrophilia. — This consists of sexual intercourse with the dead.
Some authors have suggested tliat the choice of a chronically sick or
severely crippled partner is really a modified variety of necrophilia.

Vety few cases of true necrophilb have been investigated. In some
eases it appears to be due to mild mental defect in a solitary shy
gravedigger. In others it has been suggested that the perversion is
due to the patient having had a parent who suffered from a prolonged
fatal Illness, One case has been reported of a VTry sadistic man who
mutilated corpses and had sexual interaaurse with them. In this way
he spared human beings from tlte serious consequences of his sadistic
perversion.

Fetishism. — In this pen’ersion sexual satisfaction is obtained from
contact with an inanimate object. Some subjects need a partner with
a particular feature, such as large breasts, a crippled arm, dwar&m,
and so on. This abnormality has been considered to be allied to true
fetishism.

The fetish object may be gloves, underclothes, shoes, handbags,
pieces of material, fur, rubber sheeting, and so on. The fetishist may
masturbate into the object or he may get the most sexual pleasure when
he steals the object. Thus some patients steal female underclothes
from dothcs-llncs, others cut off schoolgirls’ plaits, and some cut
pieces of material from women’s coals and dresses. There are some
fetishists who wear a fetish object or persuade ibcir partner to wear
it during coitus; for example, the rubber macintosh fetishist may
want his partner to wear a rubber autdntosh daring iatereaarse.

Psychoanalytic Thtory, — Severe castration anxiety causes the subject
(0 turn away from the desired object so that the fetish represents a
desired partial object which has been made unrecognizable. The

SEXUAL DISORDERS

177

fetish can also be regarded as a symbolic penis, which means that the
patient is trying to control his castration anxiety by giving the woman
a penis.

Transvestism. — In this perversion the subject obtmns sexual
enjoyment from dressing in female clothes. He may admire himself
in the mirror and may masturbate or copulate while dressed as a
woman. Some of these patients get considerable enjoyment from
walking about the streets in female dress. As there is no objection to
females walking about British streets in trousers, female transvestists
do not occur in Britain.

Psychoanalytic Theory . — ^The transvestist deals with his castration
anxiety by acting as a tvoman with a penis.

Transezualism. — Patients with this abnormality have the over-
valued idea that they have the mind of the opposite sex in the wrong
body. The male patients may claim that they are changing their sex
and are frightened of all male activi^, including erections. They
may cldm that they are having periods and produce rectal bleeding to
substantiate this claim. These patients are not always homosexuals.
The cause of this condition is obscure. It is usually claimed that they
have had an unhappy childhood, with a poor father figure and a dis-
turbed relationship tvith the mother. This applies to many men who
are not transexudists. Some of these patients have succeeded in
persuading enthusiastic plastic surgeons to produce the desired type
of genitalia. In general it can be said that it is immoral to co-operate
in a patient’s delusions and perversions.

Auto-eroticism (Masturbation). — Practically all men masturbate
to some degree during adolescence. It does no physical harm, but
may produce much guilt and shame. In some rather primitive com-
munities the belief that masturbation causes tuberculosis, insanity, and
softerung of the bnun still flourishes. Masturbation is a substitute for
normal or perverse sexual activity. ^Vhile it should not be encouraged
it may be a convenient safety valve in some cases.

Male Homosexuality. —

Clinical Features . — ^The subject feeb himself sexually attracted by
other males. This attraction may be exdusive or only preponderant.
It does not exclude heterosexual activity and may be episodic. Kinsey
found that 46 per cent of the men in hb survey had had homosexual
experience of some kind at some time in their lives. He put forward a
seven-point scale of homosexuality, which ranges from the completely
heterosexual Group o to the completely homosexual Group 6 . The
other groups are: —

Group 1 : Accidental homosexuality due to circumstances, including
drunkenness.

la

178 AN OUTLINE OF PSYCHIATRY

Group z: Heterosexual activity predominates, but homosexual
incidents are more than accidental.

Group 3: These men are equally interested in both types of sexual
activity, but they are able to be completely homosexual given the
right circumstances, for example, in prison or in the armed forces.

Group 4: Mainly homosexual, but heterosexual activity is more than
accidental.

Group 5: Almost entirely homosexual, but may have occasional
heterosexual activity.

The desired homosexual partner can be classified according to the
degree of femininity as follows: (1) The feminine man (the ‘pansy’);
(2) The adolescent boy; (3) The adult male; (4) The aged male.

Some homosexuals can use any male object as a source of sexual
satisfaction. Some insist that their partner must be exactly like them
and cannot tolerate any difference In the behaviour of the partner.
Others need a virile male partner whom they can serve as a woman.
This latter attitude is not necessarily incompatible m'th heterosexual
activity. Homosexual activity covers the whole range of the perversions
and is by no means restricted to anal intercourse.

"Piychiatric Disorders and //ewo«wo/iiy.— All homosexuals ha^c
abnormal personalities in Schneider’s sense. Some do not accept their
homosexuality and become neurotic as a result of their conflicts. Others
are neurotic but do not worry about their homosexual activity. Many
are psychopathic personalities in (he Hendersonian sense (see p. 65)
and may be alcoholics and drug addicts as well. Some homosexuds
arc able to have homosexual activity only nhilc under the influence of
drink or drugs.

Sexual behaviour and the choice of object may change after a cerebral
lesion. This has been reported in patients suffering from brain damage
following head injury, encephalitis, typhus, syphilis, and senile dementia.

It has been stated that schixopbrenia and mania may release homo-
sexual behaviour. If this does occur it is extremely rare.

Aetiology . — Many psjxhiatrists have regarded homosexuality as an
inborn defect or as an inherited disorder. Kallmann found too per cent
concordance in a series of uniovular twins in which at least one member
was a homosexual. Few workers in this field are conrinced of the genetic
basis of this disorder. Recently Slater has pointed out that there is an
excess of subjects bom to elderly mothers in a series of homosexuals.
This would be in favour of the possibility of chromosome abnormalities
due to non-disjunction causing homosexuality. However, this would
also support psychological theories of the origin of this disorder, since
the youngest sons of large families often have intense relationships with
their moiheo.

SEXUAL DISORDERS

179

Endocrine disorders have no relation to homosexuality and patterns
of sexual behaviour are due to the nerrous system. Hormones can
only inhibit or excite the structures 'nithin the nervous system respon-
sible for these behaviour patterns. Thus oestrogens do not produce
homosexual behaviour in men but suppress libido irrespective of its
direction.

Lang claimed that in the sibships of homosexuals there is a gross
excess of male siblings. He suggested that the male homosexual had a
feminine genotype and a masculine phenotype. Cytological studies do
not confirm this and several subsequent investigations have not confirmed
the excess of males among the riblings of male homosexuals.

Many homosexuals date their homosexuality from seduction in
childhood. Isolated homosexual episodes in childhood probably have
no effect on a normal child, but repeated homosexual activity must have.
This particularly applies to disturbed children and children from
broken homes.

Piyehodynamie Theories. — Freud believed that about the fourth year
of life the libido became concentrated on the genitalia and the little
boy developed an Oedipus complex in which he loved his mother and
hated his father. A realization of the difference between male and
female genitalia leads him to regard the female as a castrated male and
to believe that his penis may be cut off. Oral anxieties from an earlier
stage of libidinal development may cause the boy to think that the
vagina can castrate him by biting or tearing off his penis. The boy
usually resolves the Oedipal situation by identifying with his father.
Should he fail to do this his castration anxiety may lead him to insist
that a sexual partner must have a penis. Apart from this, disappoint-
ment with the love object, in thb case the mother, causes a regression
from object love to identification, so that the boy identifies with his
mother and can only love men.

Allen has suggested that four different sets of relationships in
childhood can produce a homosexual man. These are: —

1. Hostility to the mother". The boy is unable to love his mother and
therefore is unable to love women. The institutional child is a special
case of this type of situation, since he has no permanent mother surrogate.

2. Excessive love for the mother: The boy loves his mother intensely
and father is a nonentity or does not exist. The boy moulds himself
on his mother and identifies with her throughout childhood.

3. Excessive hostility to the father: If the father is an unpleasant man,
the boy may reject his father’s mascuUnity and identify with the gentle,
kind femininity of his mother.

4. Affection for an insufficiently masculine father: A man who is not
sufficiently masculine, but hostile to his wife, may bring up a son.

ifio AN OUTtlNE OF PsrciirATRr

The boy identifies with his ^her and rejects his mother. This leads
him to reject women as partners. If the father is missing or a nonentity,
the boy may identify with a homosexual father surrogate.

As both parents are bise.tual psydiologieally it is possible that the
boy may identify with the masculine aspects of his mother when he
fails to identify with his father. In some cases where the boy has made
only a marginal masculine identification, homosexual seduction would
undermine this and cause homosexuality,

Female Homosexuality, — In Britain very few women ask for
treatment for homosexuality. This is probably because homosexual
practices by two adult females do itot constitute a criminal offence in
Britain. Apart from this, female homosexuah’ty is not regarded by the
community with such horror as male homosexuality'. Havelock Ellis
estimated that 4-10 per cent of Englbh women were homosexuals,
while Hamilton claimed that 26 per cent of American women had had
homosexual liaisons. Kinsey and his group found that by the age of
35 years 19 per cent of American women had had homosexual contact
and II per cent had had an orgasm during homosexual actinty.

Soci^ Aspects of Male and Female Homosexuality.— -In
Britain and in Western civihaadon generally male homosexuals tend
to create a homosexual subgroup. Thus there are clubs, journals, and
caf£s which cater foe homosexuals and function as contact organiza-
tions. The female homosexuals do not organize in this way.

TREATMENT OF DISORDERS OK THE DIRECTION OK
SEXUAL DRIVE

The Perversions apart from Homosexuality.— Most per%'eits
only come for psychiatric treatment when their peiverse practices have
brought them into conflict with the law. They are, therefore, not
really seeking treatment, but are trying to find a way out of the social
dilEcuhies produced by perverse practices which they enjoy and are
not prepared to give up. It is doubtful whether psychotherapy has
ever cured a perversion apart from homosexuality.

Several different workers claim to have cured isolated perversions
such as transvestism, rubber feushbm, and exhibitionbm by means
of aversion therapy. The patient is brought into contact with his
fetish and is made to vonut by means of subcutaneous injections of
gr. -ir of apomorphine at z-hourly intervals. Oswald reinforced the
drug aversion by playing a tape-recording on a continuous loop of
tape which told the patient that fib pers’crse activities made him sick.
Exhibitionism has been treated hy tesciung the patient to relax; when
he is in the relaxed state he is persuaded to imagine exhibiting himself
as vividly as possible. While he is dmng diis he is given an injection of

SEXUAL DISORDERS l8l

apomorphine. In view of the poor results of psychotherapy these
aversion techniques are worthy of an eactensive trial.

^Vhere the perverse activity is liable to lead to severe prison sen-
tences it may be advisable to try to remove all sexual drive by the
administration of large doses of oestrogens, such as stilboestrol 20-
15 mg. per day, dinoestrol IS-RS mg. per day, methallenoestril 9 mg. per
day, or ethinyloestradiol 1-2 mg. per day. Stilboestrol tends to produce
nausea and vomiting, whereas ethinyloestradiol has fewer side-effects.

The Treatment of Homosexuality. —

Indications for Treatment . — If the homosexual comes for treatment
it is important to discover why he is doing so. If it is because of criminal
proceedings or pressure from relatives it is hardly worth attempting
treatment, A useful test of the patient’s good faith is to suggest that
he tries the effect of oestrogens for a limited period. Immediate refusal
of this line of treatment indicates a lack of earnest desire for cure. It is
well known in homosexual drcles that if arrested for homosexual
practices one should, if the evidence is overwhelming, plead guilty
and say that one needs treatment to overcome this terrible affliction.
If the homosexual is lucky be will, in Britain, be put on probation
with the condition that be receives psychiatric treatment. When the
probation order comes to an end the homosexual claims that he is
cured and continues with his homosexual activities.

Eelectie Psychotherapy . — Psychotherapy is helpful in those young
men between 18 and 25 years of age who have just begun homosexual
activity and who have some heterosexual drive. In these cases the
therapist behaves as a kindly, tolerant father figure, tvith whom the
patient can identify. A careful detailed history must be taken. The
therapist must try to create an atmosphere of trust and must not
indulge in moral condemnation. In the discussion of the past all the
factors which prevented the individual from making adequate contact
TOth women must be brought into prominence. In the therapeutic
discussions the patient should come to understand the healthy concept
of heterosexual love and marriage. He must also be persuaded to be
completely honest with himself about bis homosexual tendencies and
to be constantly on the watch for the ‘unconsdous’ development of
homosexual attachments. It is amazing how these patients, apparently
unwittingly, can put themselves into a homosexual milieu. The
patient should make every effort to live as much as possible in a hetero-
sexual environment. He should be encouraged to join mixed sodal
dubs, to learn ballroom dandng, and so on. His difficulties in
handling his relationships with women must be discussed. Relaxa-
tion exernses may help him to overcome shyness and gaucherie in
female company.

iSa AN OUTLINE OF PSrCHIATRV

It is important to remember that marriage in itself is not a cure for
homosexuality. From time to time homosexuals are told to get married
by well-meaning doctors. This can only lead to rmsery and suffering
for the wife and any unfortunate children of the marriage.

Endocrine Treatment . — Oestrogens usually but not always suppress
the homosexual’s libido. This treatment may be advisable in middle-
aged homosexuals who have a prefereoce for boys. Some individuals
seem to be polymorphously perverse, so that, apart from regular
frequent marital intercourse, thej* have relations with adult men, boys,
and girls. It seems as if their excessive libido spills over into perv'er-
sions. hloderate doses of oestrogens may reduce the libido in these
men suihciently to abolish the perverse behaviour and to leave some
libido for normal sexual intercourse. C^tration has been recom-
mended for homosexual and other sexual offenders. Apart from the
gross inhumanity of tMs procedure it is not always effective, since some
subjects castrated in adult life arc still able to have sexual intercourse.

i83

CHAPTER XIV

THE TREATMENT AND MANAGEMENT OF
PSYCHIATRIC DISORDERS

GENERAL PRINCIPLES OF MANAGEMENT

I. The Interview. — An attempt should be made to obtain a reason-
able outline of the history of the illness, the family history, the per-
sonal history, and the personality, at the first interview. Wherever
possible this should be supplemented by information from a relative
or friend.

In some Illnesses, such as acute schizophrenia or severe depression
(autonomous dysthymia), the diagnosis may be made at the first inter-
view and physical treatment of some kind can be started immediately.
This does not absolve the psychiatrist from obuining a fairly detailed
account of the patient's personal history and environmental conditions,
In the present sute of our knowledge we cannot alTord to neglect any
factor which logically seems to have played a part in the causation or
prolongation of a psychiatric illness. The task of the good psychiatrist
is twofold. In the first place he must do his utmost to help his patient,
and to achieve this end he must not neglect anything which may
conceivably alleviate his patient's condition. In the second place he
must continually submit his concepts to dose scrutiny and careful
investigation. In other words, he has to have one attitude as a doctor
and another as a scientist.

The art of interviewing can only be acquired by experience. Every
effort has to be made to put the patient at ease and to create a feeling
of true sympathy, which enables the patient to talk about his difficulties
freely. It is important for the examiner not to appear censorious,
although he must not agree with delusions or false beliefs or appear to
condone grossly immoral behaviour. It may be necessary to assure the
patient that one does not doubt the reality of his experiences, but one
believes that they have been caused by a nervous illness.

The doetor toA enewon^ the patient by adrrittmg that he

too suffers from the same symptoms. This cannot help the patient
and 13 likely to undermine his confidence. It should be remembered
that the patient is coming for hdp, not for an afternoon’s chit-chat.

Criticism of fellow practirioners should never be made by the
examiner. If a patient expresses critidsm of this kind, it should

IK4 AN OUTLINE OF FSTCIIIATRY

be made clear to him that the examiner does not agree and does
not wish to hear any more criticism. The patient who is criticizing
one doctor when talking to another will be criticizing the latter in
the near future.

It may be difficult to keep the patient to the point, but a balance
must be struck between giving the patient his head and interrupting
him after every sentence. Embarrassing topics, such as sexual behaviour
and hallucinations, must not be avoided, but approached in a natural
manner. If there is an indication that the patient is depressed the
examiner must ask him if he has suicidal thoughts. The easiest way of
approaching this subject is to ask the question: ‘Do you e^•e^ feci that
life is not worth living ? ' If the answer is ‘Yes’, then the next question
must be: ‘Have you ever thought of doing something about it?’ This
will allow the patient to give detaib of any proposed or half-hearted
attempts at suicide in the recent past. Relatives often become annoyed
when they discover that the doctor has been asking the patient about
suidde and may say that the doctor is putting ideas into the patient’s
head. This is not true since most depressed patients have toyed with
the idea of death as a solution to their problems, although they may
not have actively eomemplatcd suidde. In fact many of these patients
are relieved by discussing their suiddal ideas, which they have not
dared to mention to thdr relatives. If the patient is sufering from a
depressive illness (autonomous dysthymia) he should be told tltat he
will recover and that he is suffering from a well-known nervous illness
from which recovery is the rule. It is ndther possible nor even desir-
able to institute day-and-night superv'ision of every patient with
suiddal thoughts. If the patient is in hospital the doctor in immediate
charge should make every effort to win the patient’s conSdence and
establish a good relationship with him. ‘The patient should be per-
suaded to ask for help from the nearest doctor or nurse as soon as he
feels so depressed that suidde seems to be the only w'ay out. Admission
to a reasonable hospital environment often helps the suiddal patient,
because he has been removed from a situation with which he cannot
cope and put into a protective environment in which few demands are
made of him.

2. Defining the Complaint. — The psychiatrist must always ask
himself the question: ‘Why did this patient come for help at lAirtime ?’
The initial complaint may bear little relationship to the actual reason
for the patient’s attendance at the clinic. For example, when a lifelong
homosexual comes to a dinic to ask for treatment for his perversion
it may be because he is depressed, or because he b involved in criminal
proceedings, or because a close rdadve has discovered that he is a
pervert and is insisting that he be treated.

TREATMENT AND MANAGEMENT 185

3. The Assessment of the IndividuaL — ^An unbiased assessment
of the patient’s personality assets as well as all his faults and failings
must he made as early as posMble in the illness and revie^^•ed from
time to time as new information emerges. Some doctors become so
involved with their patients that any reasonable assessment of their
patients by another doctor is regarded as a personal insult, A dis-
passionate assessment of a patient is not a moral judgement but an
attempt to separate the patient's psychic reality from the true state of
affairs.

It is very important to discover any interests or hobbies which the
patient has, because these may be developed in order to compensate
for irremediable situational dlfhculties. An interest in religion or a
sense of social service may be very valuable assets, particularly in
alcohol addicts.

4. The Environment. — The domestic, occupational, and general
social situation confronting the patient should be carefully investigated
for problems which may be causing or aggravating the nervous illness.
\Vberc possible an account of the environmental difficulties should
also be obtuned from a relative. Sometimes a visit to the home or to the
place of work by a psychiatric social worker is extremely valuable.

5. The Control of the Treatment Situation. — In hospital tlie
patient is being cared for by a welhdefined team, of which the psychia-
trist is the leading member. \Vhen the patient is living in the com-
munity a large number of different sodal agencies may play some part
in treatment and they must be properly co-ordinated. Some patients
are able to involve every possible agency in their case and to play off
one against the other. TTie treatment team must, therefore, always be
properly defined, so that there is no wasted effort and each member
of the team knows the part he has to play.

Neither the patient nor his relatives should be allowed to dictate the
type of treatment required. TTie psychiatrist should carefully esqjl^n
the nature of the treatment and why it is necessary. ^\Tien the patient's
illness distorts his judgement he should not be punished for behaviour
based on a fabe judgement. In England, fairly recently, many mental
hospital psychiatrists were in the habit of refusing to admit as a
voluntary patient someone who bad been a voluntary patient in the
recent past but had ffischaiged himself against medic^ advice. Since
many severe depressives believe that they are going to become com-
pletely mad and be locked up for years, they tend to discharge them-
selves from hospital prematurely. To refuse to readmit them is to
punish them for the effects of an illness,

^Vhere admission to hospital is essential for the proper treatment or
for the safety of the patient or others the psychiatrist must not hesitate

l86 AN OUTLINE OF PSyCHIATRY

to reconunend compulsory admission if the patient refuses to agree to
admission. Should the relatives refuse to consent to compulsory
admission, legal action can be taken in Britain {ste p. 226) to take
the matter out of their hands. Where such action cannot be taken the
relatives should be left m no doubt about their responsibility and the
fact that any otJier treatment is second best. It is not uncommon hr
severe depressives to agree to out-patient electroconvulsive treatment
and to refuse admission to an acute psychiatric unit. It should be
made clear that out-patient treatment is a poor substitute for proper
in-patient care.

Control of the situation does not mean that the doaor dominates
the treatment situation. The patient must not be regarded as the
personal possession of the psj^iatrist, the nurse, or the psychiatric
social worker. In the past the medical and nursing staff of British
mental hospitals have tended to regard the relatives of the patients as
troublesome interlopers who ititerfere with the control which the
hospital staff has over the patient. Many trained mental nurses need
to possess their patients rather like over-protective mothers. This
tendency can be corrected tactfully during group discussions. The
psychiatrist should make sure that each member of the treatment team
and the key relatives knows what part he or she has to play in the
overall plan of treatment

Another form of domination is the ‘father-knows-best* attitude,
when the doctor decides on the solution of the pauent’s problems and
tries to impose his plan for the xeorganization of the patient's life with-
out bringing the patient to realize the need for these changes. This
type of behaviour is often found among kindly but ill-informed general
physidans, who naively belies'C that once the patient has been given a
logical solution to his problems be will naturally accept it and carry it out.

The psychiatrist and other members of the therapeutic team must
be on their guard against being manipulated by the patient or his
relatives. Sometimes domestic unhappiness is turned into an illness
which is used as a weapon gainst the spouse. In general, unhappy
marriages are due to faults on both sides and it is difficult, if not
impossible, to apportion the amount of responsibility for the sitiution
between the two partners. A ‘double binding’ wife may convince the
doctor that she is in no way responriblc for her long-suffering husband’s
bad behaviour. Once this has been done the doctor may be used to
bully the husband. Some patients try to enlist everyone in their cause.
The doctor or the social worker should not become a partisan on his
patient’s behalf, particularly in marital problems.

Another cormnon form of manipulation is the resort to illness by
the petty criminal when arrested for a minor crime. Some criminals.

TREATMENT AND MANAGEMENT 187

when in trouble, can produce dinical (nctures indistinguishable from a
depressive illness (autonomous dysthymia); others develop severe
anxiety states, while some react with severe excitement and senseless
violence. If the illness has developed after arrest and before trial it
should be regarded as a psychogenic reaction which, because it is a
reaction to the arrest, cannot be held to mitigate the offence.

Some patients try to invade the therapist’s private life. This must be
resisted at all costs. Patients arc treated in the consulting room, not
over the dinner table.

6. Diagnosis. — Although occasionally emergency treatment may be
necessary before the diagnosis is certain, the old maxim, ‘Diagnosis
precedes treatment’, is just as relevant in psychological as in internal
medicine. It is fashionable in ‘psychodynamic’ cirdes to decry formal
diagnosis, but this 13 ridiculous, since a formal diagnosis may suggest
an adequate line of treatment and a prognosis. Thus the diagnosis of a
depressive illness (autonomous dysthymia) suggests a definite therapy
such as electroconvulsive therapy or imipramlne. Nevertheless, a
formal diagnosis does not exhaust all the possibilities of treatment.
It is also necessary to make a diagnostic formulation which takes into
account all the environmental difRcukies and the abnormal personality
traits which, it is reasonable to assume, have some bearing on the
patient’s illness. To put the matter in another way, one must try to
produce a comprehensive answer to the threefold question: ‘\Vhy did
thit patient break dotvn in this loay at this timet'

7. The Plan of Treatment. — ^The diagnostic formulation indicates
the plan of treatment. For example, if the domestic and occupational
situations are partly causative then one line of attack will be social
readjustment. However, if a depressive illness (autonomous dysthymia)
is also present physical treatment will also be indicated.

The plan of treatment should be re\dewed from time to time and
modified as the patient’s condition changes and new facts emerge.

INSTITUnONAL CARE

Reasons for Admission to a Psychiatric HospitaL — The only
reasons for hospital admission are to obtain treatment which cannot
be given as an out-patient or because the patient is a danger to
himself and others. The mere presence of delusions or hallucina-
tions is not in itself a reason for detention in a mental hospital.
The mm of the mental hospital is the earliest possible discharge of
the patient which is consistent with his well-being and with that of
the community.

The Acute Patient. — Acute mentally ill patients should be nursed
well away from chronic patients. Many lay people believe that there

lS8 AN OUTLINE OF PSYCHIATRY

is only one mental illness which may be mild or severe. Thus, when
a depressed patient in a mental hospital sees a chronic, somewhat
dilapidated patient cheerfully passing his water on to the flowerbed,
he feels that within a few years he wll be just as dilapidated.

Shortly after the patient’s admission a plan of treatment should be
worked out. The psychiatric sodal worker, the nurses, the occupa-
tional therapists, and other auxiliaries must know what the treatment
plan is and what part they are expected to play. The plan must be
revie\vcd at regular interval bf two or three weeks. This is best done
by holding regular weekly ward meetings which are attended by all
members of the therapeutic team.

The Subacute PatleoL — If, after 6-9 months following admission
the patient is not fit for discharge, he should be transferred to a w-ard
in which there is active occupational therapy and group activity.
Where possible the patient should be placed in a ward in which the
patients are about his age and have roughly the same behaviour
problems.

The Chronic Patient and PcbabUltatloo.— Owing lo faulty
mental hospital administration in the past many chrome schizophrenics
have been allowed to deteriorate in gloomy unpleasant surroundtogs.
In order to deal with this problem it Is necessary to process such
patients tiirough a rehabilitation ward, which will encourage them to
work at the highest possible level consistent with their schizophrem'c
defect. These patients should be organized into groups in charge of
one nurse and be put to work on some task which has a useful end-
product and a reasonable flnandal reward. Every effort must also be
made to restore the patient's sense of persona] identity. He must be
given his own clothes and have adequate wardrobe and locker space to
store his personal effects.

The General Principles of Alenta] Hospital Organization. —

Segregation on llie Basis of Deharimr . — Patients should be allotted
to wards, not on the basis of formal diagneats, but on the basis of their
need for supervision. Turbulent patients, and those lacking in initia-
tive and faulty in their toilet halrits, should be nursed in small wards
with a high nurse-patient ratio. Those requiring little supervision can
be nursed in larger ward units, preferably with a large number of
separate single rooms which will give those patients who can appreciate
it a reasonable amount of privacy. Such wards have a low nurse-
patient ratio. Intermediate wards with a moderate number of patients
and a moderate nurse-patient ratio can accommodate those patients
needing some degree of supervision.

If it is mental hospital polity to admit senile patients then geriatric
wards must be organized. TTiere should be one such ward for

TREATMENT AND MANAGEMENT

lions and the physically ill and another long-stay wTird for
sclerotic and senile dements. The geriatric wards should be
ground floor with easy access to a garden.
k . — ^^Vhere possible every patient should be grinfully employed,
-aditional occupational therapy in Britain and the United States
very valuable. Patients should be employed on work with a
e end-product and which yields a reasonable financial incentive,
tain today because of ‘full employment’ it is possible to obtain
ct work which can be carried out in the hospital workshops.
;nior member of the nursing staff should act as 'Works Officer’.
Duld obtain suitable contract work and organize suitable occupa-
within the hospital. He should also be responsible for super-
the patients who are working in the hospital services such as
tchens, the maintenance services, and so on.

-govemmenL — ^The patients should be given as much responsi-
for the organization of their social life as is possible. Ward
ittees of patients should be set up. These can organize the tvard
> and social activities, such as whist drives, beetle drives, play
gs, discussion groups, and so on. A central patients’ committee
I be organized to arrange social activities for the whole hospital,
iifferent committees will, of course, need help from the doctors,
ursing staff, the occupational therapists, and the psychiatric
workers, but as far as possible the patients should be encouraged
their own initiative.

’ Therapeutie Commumly . — All the measures so far discussed
a part of the ‘therapeutic community’. This term means the
ization of the hospital in such a way that every influence to which
itient is subjected is brought into the general plan of his treat-
The most important result of a well-organized therapeutic
unity in a hospital with an enthusiastic medic^ and auxiliary staff
effect on the morale. The optimism and enthuriasm which are com-
ated to the patients and their relatives help them tremendously,
i' Patients . — Some patients, especially young schizophrenics, may
to readjust to the outside world by living at home and working
hospital by day,

•ht Patients . — Some patients with difficulties at home may find
er to live in the hospital at night and go out to work during the
Once they have made a reasonable occupational adjustment they
1 be encouraged to find suitable lodgings. This prindple can be
led and separate night hospitals or hostels may be organized in
ir the mental hospital or in a nearly Iai^ town. As a result of
:w legislation in Britain the local authorities are obliged to estab-
ostels for patients fit to live in the community.

190 AN OUTLINE OF PSYCHIATRY

The Day Hospital. — ^This la best ated in a large centre of population
away from the mental hospital. It is organized to give the various forms
of treatment such as clectroplexy, psychotherapy, drug treatment,
occupational therapy, and so on. The patients attend the day hospital
for five and a half days a week.

In large centres it may be necessary to have three different types of
day hospital or three major ditirions of a day hospital, in order to deal
with the three groups of patients suitable for day hospital care. These
are the acute patients, the chronic schizophrenics, and the geriatric
patients. ^Vhere possible the latter group should be accommodated in
a special section of an ordinary geriatric day hospital. In some parts
of the world the same building has been used as a day and as a night
hospital.

The General Hospital Psychiatric Unit. — ^The modem trend in
Britain is to build no more mental hospitals, but to establish acute
psychiatric units in the general hospit^. These are envisaged as
consisting of 40-6o.bed units with day hospital facilities and an out-
patient service. These units should help to bridge the gap between
psychiatry and the other specialities. However, it is important that
the work of these units should be closely co-ordinated with the work
of the mental hospital, so that there is a properly integrated community
mental health service.

The Community Mental Health Service.— Ideally the mental
hospital should be regarded by the community which it serves as the
centre of the mental health services. A close relation between the
hospital and the commuruty must be built up. It is partly brought
about by the hospital organizing extramural services, such as out-
patient clinics, in the general hospitals throughout the area served by
the mental hospital and also by domiciliary visits by doctors from the
mental hospitals. Open days at the ment^ hospital when anyone can
visit the hospital and get to know the svork which is being carried on
are very useful. So are mental health exhibitions held in conjunction
with the local authority. The orgaruzation of an association of friends
of the hospital can be very useful in establishing good relations between
the hospital and the community. These associations can be formed
with the help of cx-paticnls, the relatives of patients, and people
anxious to sen’C others in some way.

In Britain the local authorities, apart from duties in connexion with
the admission of patients to mental hospitals, have duties in connexion
with after-care and are obliged to provj'A adeejuate hostel accommerda-
lion for mentally handicapped patients who arc fit to live in society.
This means that close co-operation between the public health depart-
ment and the mental hospital b essential. A central co-ordinating

TREATMENT AND MANAGEMENT igi

committee of representatives from the hospital services, the public
health department, and the general practitioners of the area should
help to produce an integrated community mental health service.

Clubs for Patients. — ^These can be organized by the mental
hospital, the psychiatric unit of the general hospital, the local authority,
or a voluntary organization. To obtain the best results a psychiatrist
should attend the club, but the patients themselves should organize
their own activities. Apart from social evenings, extramural activities,
such as rambles and visits to art galleries and theatres, may be organ-
ized. Sometimes attendance at a club for patients discharged from the
mental hospital is a very useful u-ay of foUowing up the patient. The
club provides a link wth the hospital and the patient can ask for help
as soon as he feels the need. Naturally the club may be an essential
part of the treatment of a shy, isolated patient.

SYMPTOMATIC TREATMENT

X. Excitement. — ^Thls canbeduetocatatoniaormaniaoranynumber
of organic states, such as delirium, epilepsy, pathological intoxication,
and so on. The treatment is obmusly that of the underlying disease,
but it may be difficult to get near enough to establish a diagnosis.

Oral Sedation . — If the excitement Is not too severe , and particularly
if It seems to be due to anxiety, the patient may be persuaded to take
a substantial dose of a quick-acting barblturat^ such as 200-400 mg.
(gr. 3-6) of qulnalbarbitone (seconal sodium), amylobarbitone sodium
(sodium amytal), or pentobarbitone (nembutal).

In delirium and in senile confusional states it may be possible to
persuade the patient to take 7'S*i5 ml. (2-4 drachms) of paraldehyde in
a draught. This is a very effective sedative, but unfortunately Its taste
and smell are revolting.

Chloral Mixture, B.P.C. (1*3 g. in 15 ml. mixture), in a dose of
15-30 ml. (J-i fl. oz.) may be very effective in excited old people, but
should not be repeated very frequently. Trichloryl is a derivative of
chloral which is presented in 0*5 g. tablets. The dose is 2-4 tablets.

Chlorpromazinc is a very useful tranquillizer, but if given orally for
excitement it should be given in the form of the elixir (50 mg. in 30 ml.
elixir). The initial dose should be 75 mg. and this should be followed
by 50 mg. 4-6-hourIy, depending on the effect.

Parentera l Administration of Sedatives . —

Morphine'. This by itself is not a sedative and may make some
patients restless by producing nausea and vomiting. In the past mor-
phine sulphate gr. J and hyoscine hydrobromide gr. have been
given subcutaneously for excitement. In frail subjects the usual doses
were morphine sulphate gr. J and fayosane hydrobromide gr.

192 AN OUTLmE OF rSYCHIATHY

Phenobarbiione injection BJ*. (200 mg.): This can be given intra-
muscularly. \Vhile it is valuable in status cpllcpiicus It i s of no value
in excitement.

Paraldehyde injection: A dose of 10 ml. can be given intramuscularly
and can be repeated 4-hourly if necessary. It is a very useful scdati\-p in
excited delirious patients. However, it tends to cause tissue necrosis, and
wthout very careful nursing abscesses can occur at the site of injection.

ChloTpromazine: An injection of 50-100 mg. intramuscularly can be
given 4-6-hourly. This is the hest_«n*^t"usculaf sedative for ex cite-
rnent . Careful watch must be kept for hypothermia and the drowsy
iciapathy typical of chlorpromazine poisoning. As soon as the excitement
is under control the minimum amount of the drug necessary to control
the excitement should be given over the next 48 hours. At the same time
oral administration of the drug should be begun and the dose rapidly
increased until the patient ts receiving 300 mg. per day during the
third day of treatment (tee p. 125).

2. Agitation and Anxiety. — In depression the accompanying
agitation is relieved by the spedfic treatment for depression so that in
in-patients there is no need to treat the anxiety symptomaticatly unless
it is very severe. Difficulty in the assessment of the improvement
produced by the specific anti-depressive measures may be encountered
when the patient has been given heavy sedation for the anxiety. If
treatment is needed for this symptom a moderate dose of a pheno-
thiazlne such as thioridazine or periqnztne should be given.

Inadequate personahties who oomptatn of anxiety and arc unable to
ivithstand the ordiiury stresses of life should not be given quick-acting
barbiturates or any other drug which causes rapid sedation. These
patients easily become addicted to quidc-acting barbiturates. If they
insist on symptomatic treatment they should given small doses of
phenothiazincs, such as perphenazine 2 mg. three times 3 day, thiorid-
azine 25 rog. three times a day, or fluphenazine i mg. daily. These
patients should be taught relaxation techniques such as autogenous
training.

Some reasonably stable personalities under se^’cre strain may find
that their anxiety is $0 pronounced that they cannot cope with the
problems of everyday life. These patients may be kept going with
small doses of sedation, such as meprobamate 400 mg. three or four
times a day. Chlordiazepoxidc xo-3omg., diazepam 5-10 mg., or
oxazepam 15-30 mg. three times a day are very effective anxiolytics.
The drug should be withdrawn as socm as the patient’s difficulties have
been resolv'ed or if there is a tenden^ to increase the dose.

3. Insomnia. —

General Treatment . — As far as possible neurotic patients should be
persuaded to try to sleep without hypnotics. If they cannot sleep they

TREATMENT AND MANAGEMENT

*93

should not read or get out of bed, but lie in bed with their eyes closed.
Some patients can be taught relaxation techniques, such as autogenous
training, which can be carried out in bed before going to sleep.

Muller-Hegemann has devised a simple relaxation technique for
insomnia. T he patient is instructed to concentrate on his breathmg.
As he breTthes in, he concentrates on the word ‘breathe’ and as he
breathes out on the word 'peacefully'. On his next breath in he concen-
trates on the words ‘let it’ and as he breathes out on the word ‘stream’.
He continues to concentrate on these words: ‘ Breathe; peacefully;
let it; stream’ keeping the words in step with inspiration and expira-
Uon. In some severe neurotics a mild hj’pnotic may be given to allow
the patient to settle down into this technique. At the end of the W’eek
the drug can be withdrawn and the patient instructed to continue with
the concentration on the words on retiring,

Depressives and very agitated patients should be given hypnotics,
but the drugs should be withdrawn as soon as possible.

Barbiturates . — Phenobaibitone is a very valuable drug in the treat-
ment of epilepsy, but it is a poor sedative and hypnotic since it must be
given in large doses to produce any sedative effect. It has been
customary to group the barbiturate hypnotics into quick-acting and
long-acting compounds, but recent investigations have show'n that it
is the size of the dose rather than the nature of the barbiturate which
determines the onset and duration of the hypnotic effect. For a long
time barbiturates %vere regarded as relatively harmless drugs, but after
some twenty years of use the addictive properties of these compounds
became obvious. More recently it has been shown that ordinary
therapeutic doses of these drugs arc habituating. In 1965 Oswald and
Priest showed that following the administration of 400 mg. of sodium
amylobarbitone at night for up to eighteen nights volunteers had night-
mares when the drug was stopped and changes in the sleep patterns
in the electro-encephalogram took over five weeks to return to
normal.

Sodium amylobarbitone (sodium amyla!) is a very effective hypnotic
in the treatment of depressive sleep disturbances and can be given in
doses of 200-400 mg. at night. This drug is also a very effective anxio-
lytic and if given as an hypnotic it may diminish anxiety during the
following morning. Quinal^rbitone (second sodium) acts very quickly
and is particularly useful In doses of 100-200 mg. in the treatment of
anxious sleep disturbance. Tuinal which is a mixture of equal parts of
sodium amylobarbitone and quinalbarbitone can be used for depressive
sleep disturbance in doses of 200-400 mg. at night. Pentobarbitone
(nembutal) is an effective hypnotic and can be given in a dose of
200-400 mg. at night.

13

194 an outline of PSTCniATRY

It must be remembered that barbiturates can be tiscd to commit
suidde, so that only small quantities should be given to depressed
patients and where possible a responsible relative should take charge of
the hypnotic drugs and issue them to the patient as required. If a
patient is receiving a large dose of quick-acting barbiturate at night as
a h)T 3 notic he should not be given barbiturates as anxioljtics during
the day, as he is likely to become addicted if the daily dose is above
0-8 g.

Non-barhiitiratf Hypnolia , — ^It must be remembered that if a drug
is an effective rapidly-acting sedative and hypnotic it is potentially an
addictive drug. Chloral hydrate addiction is well known, so that it is
likely that the newer chloral derivatives wil] be addictive, particularly
because they are more pleasant to take.

Chloral hydrate'. This can be taken as a mixture, such as 15-30 ml.
(^i fi. oz.) of chloral mixture B.P.C. It has a rather unpleasant
taste which is not easy' to disguise; It also tends to act as a gastric
rritant.

Welldorm {diekloralphenazoru): In 600-mg. tablets (gr. 10) this is an
excellent hypnotic, especially for old people. The dose is 2-4 tablets.

Triehloryl: This U a met^liie of chloral, which is less irritant to
the stomach and is presented as a 5oo-mg. tablet. The dose is 2-4
tablets.

Carhrcmal: This is a derivative of urea. It is presented in say-mg.
(gr. 5) tablets. The dose is from 1 to 3 tablets. It may cause skin
rashes, including purpura.

Glutethimide (doriden): This is presented as a 250>mg. tablet and
the dose is 1-2 tablets. One tablet is as effective as 1 00 mg. of amylo-
barbitone sodium and similar drugs, and zoo mg. of cyclobarbitone.

l^itrazepam {mogadony. This is a benzodiazepin and is very effective
in doses of 5-20 mg. in the treatment of anxiety sleep disturbance.

4. DepressioxL — ^Amphetamine, deitroamphctamine, and methyl-
amphetamine have all been used to relieve depression. As most
hypnotics cause an unpleasant hangover in the morning these drugs
have been used to help the insomniac to ‘get going’ in the morning.
All these drugs have a limited period of action which usually ends rather
suddenly, giving rise to an unpleasant ‘drop effect’. 'Fhcy also tend to
produce jitteriness and general restlessness. If taken after midday they
tend to produce insomnia. In an attempt to avoid the jittery side-effect
one manufacturer has put a tablet called ‘drinamyl’ on the market.
This contiuns dextroamphetamine sulphate 5 mg. and amylobarbitone
SS'Sf^S-

Unfortunately, many inadequate personalities easily become depen-
dent on amphetamines to give thm a quick lift and soon become

TREATMENT AND MANAGEMENT I95

addicted. Barbiturate addicts may take amphetamines to counter the
toxic effects of the barbiturates {see p. 1 lo). These drugs are very useful
in mild depression in middle life and may help some middle-aged
women to live a normal active life. Amphetamines should not be given
to teenagers or unstable inadequate individuals.

Other euphoriant drugs, such as methyl phenidate (ritalin), should
also be avoided in psychiatric practice. Fhenmetrazlne (preludin) is
very useful as an anorexiant (appetite reducer) but as it produces
euphoria it can be used as a substitute for amphetamine. It would
appear that even the newer anorexiants are likely to lead to addiction
in predisposed subjects.

THE PSYCHOTROPIC DRUGS

Classification. — In the past few years many new non-sedative
drugs have been introduced which have profound effects on the central
nervous system. It is difficult to classify these drugs on either a
chemical or a pharmacological basis. The following classification,
which has been suggested by Shepherd and Wing, is the most useful: —

1. The major tranquillizers.—

a. The potent phenothiazines and allied compounds.

b. Reserpine and allied drugs.

e. The butyrophenones.

2. The minor tranquillizers. —

a. Fhenothiazines.

b. Diphenylmethane derivatives.

3. Sedatives.—

a. Hypno-sedatives.

b. Tranquillo-sedatives.

4. Centrally acting anticholinergic drugs.

5. Stimulant drugs (thymoleptics). —

a. Drugs with an amphetamine-like action.

b. Anti-depressive drugs with a chemical structure resembling
the phenothiazines.

c. Monoamine oxidase inhibitors.

6. Psychotomimetic drugs. —

a. Mescaline.

b. Lysergic acid diethylamide (LSD).

f. Cholinergic blocking agents.

tf. Phencyclidine.

7. Transitional compounds. —

a. Thioxanthene derivatives (taractan).

b. Prothipendyl hydrochloride (tolnate).

c. Oxypertine (integrin).

AN OUTLINE OF PSYCHIATRY

196

1. The Major Tranquillizers. —

A. Phenotiiiazines and Alued Compounds. — ^Thc basic chemical
structure of this group consists of two benzene rings held together with
one atom of nitrogen and one of sulphur, thus: —

Different radicals can be attached in the 2 and 10 positions. These
drugs can be divided into the following three groups depending on the
side chain attached in the 10 position: (1) Compountb with an, ali-
phatic side chain ending in a dimethyl amine group; (2) Compounds
with a side chain ending in a piperidine ring; (3) Compounds with a side
chain ending in a piperazine ring.

t. Compounds tcilh an Aliphatic Side Chain ending in a Dimethyl
Amine Group.— Chlorpromazine (largactil, thorazine, megaphcn) is
the most well-known representative of this group. It has a chlorine
atom in the 2 piosition and a dimethyUminopropyl group in the 10
position, giving the foIIo^ving structure formula:—

.CH,

*cn,

The oral dose in schizophrenia ranges from zoo to looomg. per 24
hours. The usual dose is between 300 and 500 mg. per 24 hours. It can
be given intravenously and intramuscularly in doses of 50-100 mg.
The drug is an anti-emetic and tends to cause drowsiness in large
doses. Fseudoparkinsonism occurs, but not usually when moderate
doses are given. Pyrexia and hypothermia may occur and severe
hypothermic crises may be provoked in myxocdematous patients.
Skin rashes may occur in nurses handling the drug and patients taking
the drug may become very light-sensitive and easily become severely
sunburnt. In about i in every 500-600 patients a severe obstructive
jaundice develops. Very rarely the drug causes agranulocytosis.

Other drugs in this group are promazine (sparine), which has the
same radical in the 10 position and no radical in the 2 position, and
acetylpromazine (notensyl), which also has the same radical in the
IQ position and an acetyl radical in the 2 position.

TREATMENT AND MANAGEMENT

197

2. Compounds with a Side Chain ending in a Piperidine Ring . —
Mepazine (pacatal) was the first drug of this kind. Its formula is as
follows: —

a:xi»-c

This drug produces agranulocytosis and liver disease. It is not
used very much in Britain.

^ J^toridazine fmfUeril) also belongs lo this group. Its structure is
as follows: —

a:x>^

This is a very useful drug in the treatment of schizophrenia. The
dose is 300-600 mg. per 24 hours. It has no anti'emetic effect and
does not usually produce pseudoparkinsonism. Common side>efFects
are dizziness, drowsiness, dryness of the mouth, and stuffiness of the
nose. Amenorrhoea, suppression of lactation, a nd loss of sexual desire
may occur when moderate doses are given. In exceptionally large
doses of 2-3 g. in 24 hours retinal pigmentation has been reported,
but there is as yet no indication that this occurs in the dosage recom-
mended here.

Pericyazine fneulactil) is a recent addition to this group. Its formula
is: —

a:xx

'€>°

This drug has a transient soporific effect and is best ^ven twice
daily; a small dose is given at midday and a latger dose is given at night.
In the treatment of acute schizophrenia l p-^o mg. is given at midday
and 20-60 mg. at night. Thisdrugisdaimed to be effective in behaviour
disorders in abnormal personalides in doses of 5-20 mg. at midday and
10-40 mg. at night. It has also been used in the treatment of severe

AN OUTLINE or rSYCHlATKY

I9S

anxiety states in doses of 2*5-5 ®8* midday and 5-10 mg. at night In
states of severe excitement 10^0 mg. in an intramuscular injection can
be given 8-hourIy.

3. Compounds tctlh a Side Chain ending in a Piperazine Ring . — ^Ul
these drugs tend to produce pseudoparkinsonism, akithisia, and spasm
of the neck and shoulder^girdle muscles resembling torsion dystonia.

Trifluoperazine fstelaaine) is a good representative of this group,
and its formula is as follows: —

acx.

This drug is a very effective tranquillizer in schizophrenia, in which
a dose of 15-25 mg. per day usually effectively controls the symptoms.
The requisite dose is found by beginning with a dose of 5 mg. twice
a day and increasing by 5 mg. every 5 tbys until the minimum dose
which controls symptoms is reached. Occasionally doses of 35-40 mg.
per day are required. The pseudoparktnsonisrg usually occurring on
moderate dosage can be treated with antiparkinsonian drugs, such as
orphenadrine hydrochloride (dis^) 50 mg. three times a day or
benztropine me^anesulphonate («>gentin) a mg. three times a day.

' ^erphenazine'^ s another member of this group and has the advantage
that at the time of writing it is the cheapest phenothiazine effective in
schizophrenia. The dose required ranges from 26 to 32 mg. per day.
Tlus drug is also of value in controlling the excitatory aide^effects of
the thymoleptic drugs, where it is given in small doses of 2 mg. twice
or three times a day.

Fluphen2zine, (moditen> is a long-acting phenothiazine with the
following fonnula: —

a;xx., _

cn,-cn,-cii2-N N-cn,-CH,-oH

N_/

It is very useful in the treatment of schizophrenia in doses of 6-12 mg.
per day. Huphenazine enanthate can be given inframusoilarly in doses
of 25 mg. (i ml.) every 14-21 days. A test dose of 12*5 mg. is given at
first and if there are no untowa^ effects, 25 mg. is given in i week’s
time and at 2-weekly or 3-u cekly intervals thereafter. This drug is very

TREATMENT AND MANAGEMENT 199

useful be cause chronic schizophrenics, whose symptoms are well
controlled by phenothiazines, often refuse to take drugs after discharge
from hospital and subsequently relapse. Such patients may be ■nell
controlled on fortnightly injections of fluphenazine enanthate. As this
drug causes marked pseudoparkinsonism, patients must also be given
antiparkinsonian drugs.

B. Reserpine and Allied Compounds. —

Reserpine . — ^This is an alkaloid from the Indian plant Rauzcolfia
serpentina, which has been used for centuries by the Ayur-Vedic practi-
tioners of India for the treatment of insanity. This drug produces
hypothermia, hypo t ension. %Yater retention, and an increase in appetite.
It is a very effective tranquillizer in schizophrenia, but it tends to
make many patients depressed and unhappy and is likely to provoke
epilepsy in predisposed subjects. It can be given to disturbed schizo-
phrenics in doses of 6-12 mg. per day. If electroconvulsive therapy
is given vrithin five days of the administration of reserpine prolonged
apnoea or death may occur. Some physicians still prescribe this drug
in small doses for the treatment of essenrial hypertension. Even in
such small doses reserpine may cause a typical depressive illness f auto-
nomous dysthymia), which does not^prove when the drug is dis-
continued, so that thymoleptics or electroconvulsive treatment may
be necessary.

Allied Compounds . — Tetrabenazine (nltoman), unlike reserpine, has
no indole nucleus in its structure. It acts more quickly than reserpine
and is effective in doses of up to 200 mg. per day in the treatment of
schizophrenia. The usual dose is 120-150 mg. per day. When given
in high dosage it tends to produce pseudoparkinsonism. This drug
does not appear to have any advantage over the phenothiazines.

C. The Butyrophenones. — Haloperidol (serenace) has the follotving
formula; —

This drug is very useful in e xcitement due to mania or schizophrenia.
The initial oral dose is 6 mg. per day and this can usually be reduced to
3 mg. per day once the symptoms haw been brought under control.
In severe excitement 5 mg. of haloperidol can be given intramuscularly
or intravenously and repeated 6-hourly until the excitement is under

202

AN OUTLINE OF PSYCHIATRY

It IS a very effective anxiolytic in doses of 15-30 mg. three times a day.

4. Centrally Acting /UitichoUnergic Drugs.— Benactyxine (sua-
vitil) is the only drug of this kind in clinical use. It has been used in
the treatment of anxiety states, phobic states, and mild depressions.
There is no dear evidence that it is of any value.

5. Stimulant Drugs (Thymoleptlcs). —

A. Amphetamine-like Drugs. — Amphetamine and its deri\’atives
have already been discussed (ree p. 194). The more recent members of
this group, methyl phenidate (ritalin) and pipradol (meretran), are of
no real value in the treatment of depression.

B. Tricyclic Anti-dcpressive Drugs. — Imfnramine was the first
drug of this kind to be used for the treatment of depression (autonomous
dj^thymia). It has the following chemical structure; —

, /™‘

Vh.

The standard scheme of dosage U 25. mg. thieejimes a day for one
week, rising thereafter by 25 mg. every second day until the main-
tenance dose of 50 mg. three times a day is readied. Usu ally the dru g
hasng cffect.jintil 1 0-21 d aya^ftetit isAsi given, and if there is no
(effect after four weeks it should be discontinued. If the drug relieves
^the depression it should be continued at 50 mg. three times a day for
|a further four weeks and if improvement is maintained the dose should
be reduced to 50 mg. twice ^ily. If, after a further four weeks, the
. patient is well it should be reduced to 25 mg. twice daily for a further
* four weeks, after which it can be discontinued if the patient remains
5^11. Should symptoms recur when the dose is reduced the patient
should be given the previous dose of the drug. The patient should be
warned not to stop taking tlie drug suddenly as this may produce a
rapid worsening of his depression. Before the drug produces its anti-
depressive effect it may cause an unpleasant excitement and insomnia,
particularly in anxious depressives. To avoid this side-effect a small
dose of phenotbiazine, such as perphenazine 2 mg. or thioridazine
50 mg. three times a day, should be given.

Sirfe.pffecfaa re common during treatment with imipramine adminis-
tration. These are dryness of the mouth, difficulty in accommodation,
tremor of the hands, constipation, excessive perspiration, and dizziness.
Complications such as skin rashes and sudden foils occasionally occur

TREATMENT AND MANAGEMENT

203

but only when high doses of the drug are given. Side-effects tend to
be more severe in old people and in order to avoid them the dosage
for patients over 60 years of age should be reduced to 10 mg. three
times a day rising to 20 mg. three times a day.

Pertofran, a norimipramine, has been introduced. Since it is a
metabolite of imipramine It is supposed to act more quickly than the
original substance. It has not not been shown conclusively that this
drug is an improvement on imipramine.

Amitriptyline (tryptizol) is chemically similar to imipramine and has
the following chemical formula: —

cc;!X)

CH-CH,-CHj-N

This drug has an immediate tranquilUaing effect and an anti-depres^
sive effect which only becomes m anifes t after 10-21 days . The dose is
25 mg. three times a day and if there is no effect after three weeks it
can be increased to 50 mg. three times a day. The most common side-
effect is dryness of the mouth, but some patients ffnd that the dnnvsi-
ness and apathy produced by the drug are insupportable.

Nortriptyline {allegron, aventyl) has the following structure: —

ego

CH-CHj-

The dose is 25 mg. there times a day. Dryness of the mouth is afrequent
side-effect. Drowsiness is not as frequent nor as severe as with
amitriptyline.

Trimipramine. (surmontil) is an effective anti-depressive and is given
in an initial dosage of 25 mg. threetimesaday, which is raised by25 mg.
every second day during the second week of administration until a
maintenance dose of 50 mg. three limes a day is reached. This drug
has a tranquillizing and soporific effect. The latter tends to wear off
after a few days.

Protriptyline (concordin) has the following chemical formula: —

COO

H CH,-C

AN OUTLINE OF PSTCilfATRr

204

It is claiined that this is a rapidl/ acting drug with relatively few side-
effects. The dose in a moderately severe depression is 20 mg. three
times a day for one week and 10 mg. four times a day thereafter.

Pramindole (prondol) is a tri(^xUc drug which is an indole deri\ative.
Its formula is: —

The dose is 30 mg. three times a day, but if there is no response it can
be raised to 60 mg. three times a day. Unlike the other tricyclic anti-
depressants this drug has only very slight atropine-like side-effects.

C. The Monoamine Oxidase Inhibitors. — These compounds
inhibit the enzyme monoamine oxidase, but the relationship bettveen
this action and their anti-depressive effect is uncertain. Most of them
are hydrazines, having a NH»NH linkage, but tranylcypromine
(parnate) is not.

Nialamide (niamid) appears to be of little value, while pheniprazine
(cavodil) may produce severe jaundice and has therefore been with-
drawn from the market.

Phenelrine (nardil) has been claimed to be an effective anti-depres-
sire. The standard dosage is 15 mg. three times a day, but in severe
depressions as much as 75 mg. a day may be given. Side-effects are
dizziness, hypotension, swelling of the ankles, exdtement, and con-
fusion, but on the whole serious side-effects arc rare. Like imipramine
this drug may at rirst increase anxiety and restlessness, so that small
doses of phenothiazines should be given during the first few weeks of
treatment (tee p. 202).

Tranylcypromine (parnate) is another member of this group and,
like phenelzine, initially increases Station. The usual dosage is 10 mg.
twice daily. This drug is also presented in combination of jo mg. with
I mg. of trifluoperazine under the name of ’parstelin’. One tablet of
this compound can be pv«i twice daily. The m3|or side-effetfs of
tranylcypromine are headache, dizziness, and hypertensi^e attacks.

These compounds may cause very severe reactions when given
together with «rtain other drugs. If a patient who is receiving a
tmonoanune oxidase inhibitor is given meperid^ (pethidine) coma
^Tand death may occur, wfuSe amphetamine wuV bring ahouf a severe
[hypertensive attack. ^\'hen these drugs arc combined with reserpine
or ee-methyldopa (aldoroet) exdtement and confusion develop. How-
ever, from the point of view of psychiatric treatment the most

TREATMENT AND MANAGEMENT

205

dangerous combination is with the tricyclic anti-depressive drugs,
because this is likely to produce cardiovascuhc collapse and even death.
Imipramine and similar drugs should not be administered for at least
14 days after the cessation of a monoamine oxidase inhibitor, because
the level of monoamine oxidase does not return to normal until 7-14
days after the inhibiting drug has been stopped. Since the value of
monoamine oxidase inhibitors is doubtful and they produce serious
complications, the present author no longer uses them and considers
that amitriptyline is the drug of choice in the treatment of agitated
depression and imipraminedn the retarded depression.

It has been claimed that the monoamine oxidase inhibitors are useful
in reactive depressions and imipramine is the drug of choice in so-
-called ‘endogenous* depres sions . Since the workers who make these
claims fail to give a reasonable delineation of reactive and endogenous
depressions it is difficult to evaluate their results. However, it would
appear that much of what the present author would call ‘secondary
autonomous dysthymia’ is called ‘reactive depression’ by others.
Another claim which is widely quoted is that the rnonoamine oxida se
inhibitors are useful in ‘anx iety, hy steria* occurring in middle life in
previously reasonable” perwnaliiies. Some patients with mild auto-
nomous dysthjTnia present with marked anxiety, fears of leaving their
homes on their own, being left on their own, or, occasionally, of travel-
ling. Careful questioning of the patient and his relatives reveals obvious
depressive symptoms. Such patients often respond well to drug treat-
ment. In view of the relative freedom of amitriptyline from side-
effects any patient suffering from an acute anxiety state which might
be an atypical depression should be given amitriptyline for a few weeks.

6. Psychotomimetic Drugs. — This is a steaily growing group of
drugs tvith many different chemical structures which produce a con-
fusional state when given to human subjects. These drug-induced

g ychotic states are known as ‘ model psychoses* a nd are charactenzed
r _d isorder3 of mood, perception, and thinking, which are often
mistakenly compared with the symptoms in acute schizophrenia. Some
are interesting since they resemble the catechol amines and 5-hydroxy-
tryptamine which are normally found in the mammalian nervous
system. Only a few of the psychotomimetic drugs can be discussed here.

A. Mescaline. — ^This drug resembles adrenaline and this is seen
deacly %vhen the famiulse are compared, as falhirs : —

CHOH-CH,-NHCH,

Mescaline

Adrenaline

TREATMENT AND MANAGEMENT

20-J

N-methyl-3-piperidyl benzilate, tvhich has the following formula: —

In small doses of 10-15 mg. by mouth this drug causes anxiety,
depersonalization, delusions, and dilhculty in concentration.

D. Phencyclidine (Sernyl). — This drug resembles meperidine
and was first used as an anaesthetic, because it probably blocks the
sensory input at the level of the thalamus and midbrain. It has been
claimed to be of value in the treatment of obsessional states. It can be
given by intravenous injection in a dose of 0*075 "’g-Ag* body-weight.
The formulae of sernyl and meperidine are as foUotvs: —

Semyl Meperidine

The value of these psychotomimetic drugs in psychiatry is still
uncertain. The psychoses produced by them are fascinating and it is
possible that biochemical investigations of these disorders may throw
considerable light on the acute organic psychoses. The author is not
con\dnced that these drug-induced psychoses can help in elucidating the
causes of the functional psychoses.

7. Transitional Compounds. — ^There are a few drugs which do
not fit elsewhere in this classification.

A. Thioxanthene Derivatives. — Chlorprothixene (taractan) is the
member of this group which has been used in psychiatry. It is claimed
to be a sedative, anti-depressive, and tranquillizer. The chemical
formula is as follo^vs; —

exXX

CH-CHj-CHj-N

CHj

20 S

AN OUTLINt OF PSYCHIATRY

It is presented in 5- and tj-mg. tablets and in ampoules containing
50 mg. in 2 ml. The usual dosage for schizophrenia, obsessional
states, and confusional states is 90-^00 mg. a day; for depression it
is 60-120 mg. a day; for neurotic conditions it is 30-90 mg. a day.
The commonest side-effect is drotvsiness, but hypotension and pseudo-
parkinsonism may also occur with high dosage.

Thiothixene (navanc) is another member of this group, which has
been recently marketed in Briuun. Its formula is: —

SO,-N(CIl,)i

CII-aii-CH,-N N-CHi

The initial dose in the treatment of schizophrenia is ro mg. and this is
gradually increased until an effective dose level is reached. The
maximum beneficial dose rarely exceeds 60 mg. a day. Side-effects are
similar to those of trifluperazine.

B. PROTHtPENDYc HviJROCTiLORtoe (Tolnatc).— T his drug has the
following chemical structure, similar to promazine; —

CH.

CH,-CH,~CH,-N

'CH,

Tolnatc is presented m 20- and 4o-mg. tablets and in ampoules
containing 40 mg. of prothipendy] base in 3 ml. It has been used in a
dosage of 240-960 mg. per day in acute schizophrenia and excited
confusional states, while in anxic^ states the usual dosage has been
80-120 mg. per day. The side-effects are tachycardia, hypotension,
photosensitivity, and epileptic 613. It is too early to be certain of the
precise value of this drug.

C. OxYPERTiNE (Integrin). — ^TW s drug has the following formula
and is quite unlike other tranquillisers: —

H3COy^ i

.CH,-CH,-N

00

It is useful in the treatment of withdrawn and apathetic schizophrenics.

TREATMENT AND MANAGEMENT

209

The oral dose is 80 to 120 mg. daily in divided doses, but in acute cases
larger doses may be given, although the total daily dose should not exceed
300 mg. This drug may produce akithisia and pseudoparkinsonism.

PHYSICAL TREATMENTS

I. Insulin Corns Therapy. —

Technique . — ^This treatment is carried out on five or six days of the
week. The patient is given increasing doses of insulin intramuscularly,
starting with 20 units and increasing each day by 20 units until the
patient passes into coma. Once the coma dose has been found, it is
reduced by 40 units and the patient usually continues to have comas
when this smaller dose is given. The patient fasts from 8 p.m. on the
night before and is given the insulin at 7 a.m. on the day of treatment.

The stage before coma is known as ‘sopor’. In this state the patient
is very confused, but is able to carry out some purposive responses.
The occurrence of coma is marked by the loss of all purposive re-
actions. The patient is never allowed to remain in sopor for longer
than an hour, ^\'hen the first coma occurs it is terminated after ten
minutes by the administration of a 33 per cent solution of sucrose in
tea through a stomach-tube. If this fails to rouse the patient an intra-
venous injection of a strong glucose solution must be given. The
usual course of treatment consists of thirty comas each lasting half
an hour.

The main danger is so-called ‘irreversible coma’, when the patient
fails to recover when his blood-sugar returns to normal. This may
lead to death or severe brain damage.

This treatment is usually given in special units staffed by nurses
trained in the special techniques. The patients are treated as a group
and when not receiving treatment take part in various group activities.

Indications . — The enthusiasts for this treatment claimed that it was
indicated in acute and subacute schizophrenia in patients under 40
years of age. It has always been claimed that the early cases of scliizo-
phrenia responded best to insulin therapy, but these are precisely the
cases where the diagnosis of schizophrenia is most in doubt. Many of
the exponents of this treatment had a very wide concept of schizo-
phrenia.

Results . — It is usually claimed that insulin therapy, if used during
the first year of iJlness, brings about more than twice the number 0/
remissions which would be expected to occur spontaneously, while
during the second year it increases the number of remissions, but not
to the same extent as in the fimt year. Unfortunately this treatment
was never subjected to a controlled trial, so there is no clear evidence
that it is of any value in the treatment of schizophrenia. Recent work

*4

210 ATi OBTtlNE OF PSyCUIATfly

has shown that it is no mote valuable than baibhurate sleep. Since
the introduction of the major tranquillizers, insulin coma therapy has
virtually ceased in Great Britain.

2. illodified Zosalin Therapy. —

Technique . — ^The patient fasts from 8 p.m. and is given 20 units of
insulin intramuscularly at 7.30 ajn, the following ^y. After three
hours he is encouraged to eat a hearty breakfast. The dose of insulin
is increased by to units every day until a maintenance dose of 60-
leo units is reached. The maximum dose of insulin should produce
moderate sweating and slight drcsv-uness. If the patient passes into
moderate or deep sopor he should be given sugared tea and encouraged
to eat a good breakfast as soon as he is able to do so.

Indications . — ^TWs is a useful treatment for severely disturbed
neurotic patients who are so distressed that they require to be removed
from their domestic environment. The increase in weight tends to
cause a sense of bodily well-being and the physical effects of the
insulin have a marked suggestive effect.

3. Electroconvulsive Treatment. —

Technique . — An alternating electrical current is passed through the
head by means of electrodes applied to the temples. The areas of skin
CO tvhtch the electrodes are applied are cleaned trith ether or epirit and
then moistened with saliite. Many different machines have been
devised to provide an electrical current at a safe voltage and amperage.
In Britain the ‘Ectron’ machine, which consists of a transformer and
a press-button switch, is the most popular. It has a red pilot light which
indicates that a current is fiomng through the prirnary winding of the
transformer, and a white indicator light wWch indicates that the
patient has been connected to the secondary winding of the trans-
former when the preM-button switch is depressed. This switch is
pressed for 3-5 seconds, by which time a fit should begin.

^Vhen the circuit is completed a violent extensor jerk of the whole
body takes place. This is followed by an epileptic fit lasting for 45-120
seconds and when this ends there is a short period of apnoea lasting
for a few seconds and then consciousness slowly returns.

The main disadvantage of this treatment is the occurrence of frac-
tures of the vertebral bodies and occasionally of the long bones. In
order to avoid this complication the treatment should be preceded by
anaesthesia and a muscle relaxant. The usual anaesthetic is o-a-
0-25 g. of sodium thiopentone or o*i g. of methohexitione sodium
intravenously. The synnge is then changed and 30 mg. of suxame-
thonium chloride (scoline) is injected intravenously through the same
needle. This amount of muscle relaxant should reduce the force of the
fit considerably. If it is not very effatise the dose should be increased

TREATMENT AND MANAGEMENT 2II

to 40 mg. at the next treatment Sometimes, because of a previous
fracture or joint disease, it is necessary to relax the patient completely
and this can be done by increa^ng the dose of suxamethonium chloride
to 50 mg. Even when complete relaxation has been produced it is still
possible to see some evidence of a convulsion, because there is twitching
of the orbicularis oculi and of the toes. The full dose of suxamethonium
chloride produces a profound muscular relaxation for 4-5 minutes.
When sodium thiopentone and a muscle relaxant are used with electro-
convulsive treatment they should be ^ven by a trained anaesthetist who
should be prepared to intubate if necessary, and an adequate apparatus
for artificial breathing should be available.

The Rigime , — In subjects under 45 years of age the first six treat-
ments can be given three times a week, but further treatment should
be given twice weekly. In subjects over 45 years of age treatment
should be given twice weekly, because these patients tend to become
confused rather quickly if treatment is given more frequently. Nearly
all patients show some degree of confusion after receiving six treatments
within a period of three weeks. TTus confusion and the accompanying
memory loss may not be obvious in the hospital environment because
not many demands are made on the patient’s intelligence and memory.
It is advisable not to allow patients receiving electroconvulsive treat-
ment to go home on leave until some days ^ter the last treatment as
they may become very distressed when they find that they cannot
remember simple things which crop up in conversation with friends
and relations. Patients must be reassured that the memory difficulties
will improve after the treatment stops.

Apart from a very small group of manic-depressives suffering from
depression, who recover rapidly, most patients need at least six treat-
ments. A good general rule is to give the patient a further Uto treat-
ments after he appears to be well. Many patients are frightened of
the treatment and try to convince the doctor that a moderate response
is a complete recovery. If no response occurs after twelve treatments
given twice or three times a week it is unlikely that the patient will
improve with further treatment. It is wisest to stop the treatment if
this happens and to wait two or three months before giving a further
course.

All patients become confused to some extent after electroconvulsive
treatment and this clears up within three ^veeks. If a patient is em-
ployed in some type of intellectual work he should not return to it
until at least three weeks after his last treatment. As a general rule, it
is only after the confusion has died away at the end of the first three
weeks after the cessation of treatment that the immediate effect of the
therapy can be assessed.

212 AN OUTLINE OF PSYCHIATRT

Some patients make a slight or temporary recovery with electro-
convulsive treatment, but after a further period of a few months clectro-
plexy may produce a complete recovery.

Indiealions . — In severely depressed suicidal patients cJectroplcxy is
the treatment of clioice; it will benefit depressives who have made no
response, or only a partial response, to drugs.

It is also indicated in tlic cycloid psyclioses {tie p. 131). In acute
schizophrema In which there h catatonic stupor or marked depression
clectroplcxy Vi-ill remove these unpleasant symptoms and make the
patient more accessible.

This treatment has also been used in the past to control violent
unruly schizophrenics and has euphemistically been called ‘main-
tenance E.C.T.’ This is likely to produce brain damage. Since the
introduction of the phenolhiazines and other tranquillizers there is
c\’en less jusUHcation for this type of treatment.

In some centres E.C.T. has been given extensively to out-patients.
This should be regarded as a second-best line of treatment. If the
depressive (autonomous dysthymic) is left at home he ttill find It
difficult to cope with his environment because of the increasing confu-
sion; female patients may be expected to continue svith most of the
domestic chores. If out-patJent E.CT. is given it must be carefully
explained that the patient is til and should be treated as an invalid
duriog, and for three iveeks after, the treatment. There is, of course,
less objection to the administntion of E.CT. to a day hospital patient
as he is in a reasonably well-controlled environment and can obtain
reassurance very easily.

Contra-indieatuim . — Congestive heart failure, cardiac infiurtion
within the preceding six weeks, and a previous history of subarachnoid
haemorrhage are all absolute contra-indications. If the patient has
active tuberculosis or has had active tuberculosis in the preceding
year E.C.T. can be given, but antibiotics, such as para-aminosalicylic
acid (P.A.S.) and streptomycin, should be given and continued for at
least six weeks after the electrical treatment is stopped.

Old age is not a contra-indication to E.C.T. as long as the patient is
otherwise physically fit.

4. Electronarcosis. — A continuous current is passed through the
head by means of a special machine which compensates for the varia-
tion in the electrical resistance of the head. This produces a state of
unojnsciousness which is referred to as ‘narcosis'. There is no evidence
that this treatment is of any value.

5. Prefrontal Leucotomy (Lobotomy).—

Technique . — ^This operation con^ts in severing the fibres which
connect the frontal lobes with the thalamic nuclei, particularly the

TREATMENT AND MANAGEMENT 213

dorsoraedtal nuclei. For many years the standard technique was that
of Freeman and Watts, which consisted in inserting a needle through
a trephine hole in the skull made according to certain measurements.
The needle is passed down to the orbital surface of the frontal lobe
and its tip is swept laterally in an attempt to sever most of the con-
nexions of the frontal lobe with the thalamus. Since 1950 this operation
has fallen into disuse and has been replaced by more selective opera-
tions aimed at cutting through or destroying the fibres from the orbital
surface of the frontal lobe which run to the thalamus. Two such
operations are bimedial leucotomy and blind rostral leucotomy.

Bimedial leucotomy. Trephine holes are made on either side of the
superior longitudin^ sinus immediately in front of the coronal suture.
The white matter is cut in a plane which is bounded above by the
superior border of the frontal lobe 2 cm. anterior to the coronal suture
and below by the sphenoidal ridge. This plane runs medial to and just
anterior to the frontal horn of the lateral ventricle.

Blind rostral leucotomy. Trephine holes are made just anterior to
the coronal suture and a brain needle is inserted and passed dotvnwards
and forwards towards the frontal pole. It is then angulated laterally
for about 2 cm. at the lower end.

Complications . — Haemorrhage and the usual complications of a
surgied operation may occur. With the older classical operation a
few padents developed widespread trophic lesions of the skin and died.

The major psychiatric complication is the occurrence of a severe
frontal lobe syndrome, in which there are apathy, indifference, and an
inability to plan ahead (see p. 146). However, this should not occur
with the modified operations described above.

The other important complication is epilepsy, and to avoid this the
patient should be given phenobarbitonc gr. i (sz'Snig.) twice daily
for the year foUmring the leucotomy. If at any time after the patient
has been leucotomized it is necessary to prescribe a phenothiazine
drug, then the patient should also be gjven phenobarbitonc, because
phenothiazines are likely to produce epileptic fits in the predisposed.

Judications , —

Schizophrenia'. The operation was useful in schizophrenics suffering
from insistent hallucinations and affect-laden delusions. Such patients
arc now helped considerably by phenothiazines.

Cferotttc djeprtiWM (outonomout dytthymia); PatienU with, a gaod
previous personality and a depresrion lasting for two years or more
who fail to respond to electroconvulsive treatment often make a good
improvement with leucotomy. Since the introduction of the new
thymoleptics such patients seem to have disappeared.

Obsessional states: Severe incapacitating obsessional states which
have been treated conservatively for several years without improvement

214 an outline op PSTCniATRY

should be considered for leucotomy. A good previous personality and
the absence of abnormal personaliqr traits suggest a favourable outcome,
Tho'ie obsessional states where there is marked involvement of others in
the obsessional symptoms and tll*controlled aggression are not suitable
cases for the operation because it may release unpleasant behaviour.

General ConsiJeralions, — Leucotomy should never be regarded as the
first line of treatment but should be thought of when all other methods
have failed and the patient has been ill for a few years. In senile depres-
sives •nho have retired Irom ttork it may be considered at an earlier
stage in the Illness, because a mild frontal lobe sj'ndromc in an old
person being cared for at home is unimportant compared with the
same symptoms in a middle-^ed patient who may be made incapable
of bolding dowTi a responsible job.

It seems paradoucal to destroy a part of the brain to cure a mental
disease which Is probably due to a disease of the brain. The psychiatrist
would do well to remember the words of Isaac Judaeus, who wrote:
‘Treating the sick is like boring holes in pearls, and the physidan must
act with caution lest he destroy the pearl committed to Ids charge.’

6, Other Physical Treatments.— A large number of other physical
treatments, for example, continuous narcosis, intravenous acc^Icholine,
etc., have been used in psychiatry. There is no evidence that these
treatments arc more than psychotherapy by suggestion.

PSYaiOTlIERAPY

>. General Discussion.—

Phyneal versus Psyehohgieal Treatment. — In order to organire our
knowledge it is necessary to use an rmpiriral dualism and to look upon
the mind and body as separate entities when, in fact, they are merely
different ways of looking at a living organism. This naive dualism is
often carried over into psychiatry, so that psychotherapy is regarded as
dealing Nvith a bodiless mind and physical treatments >vith a mindless
body. It is tempting to regard the complete change of the personality
produced by psyclioanalysis as a physiological change and to compare
it tvifh the permanent changes In animal behaviour which Pavlov and
his pupils produced during conditioning experiments. On the other
hand, it seems just as likely that many of the successful results of
physical treatments are due to suggestion. The distinction beween
psychotherapy and physical treatments in psychiatry is not as sharp
as would appear at first sight.

The Problem of Transference. — Freud pointed out that during psycho-
therapy the patient identifies the therapist with a parent or some other
person who has played an important part in the patient’s childhood.
The patient, therefore, transfers to the therapist all the emotions which

TREATMENT AND MANAGEMENT 215

he had in relation to this person. The neurotic ^mptoms and attitudes
become attached to the treatment situation so that the illness becomes
a transference neurosis. During the analysis the patient works through
his emotional difficulties and is finally cured when they have dis-
appeared. ^Vhen this happens the transference situation is resolved
and the patient no longer has any emotional dependence on the therapist.

Since ambivalence, or positive and negative feelings towards the
same object, occurs in all emotional relationships, the patient both
loves and hates the therapist. As the treatment progresses the negative
aspect of the relationship may become very pronounced, or, in other
words, negative transference occurs. The therapist also develops a
transference and identifies the patient with some important person in
his life. This is called the * counter transference ’ andit too can be positive
or negative.

Transference and counter transference occur to some degree in all
doctor-patient relationships and every doctor must train himself to be
fully a^vare of the transference situation. Many patients improve
immediately with any kind of treatment because they wsh to please
the therapist and to preserve the love and attention wWch they receive
from him. The improvement is, therefore, dependent on the main-
tenance of the transference situation, so that the improvement is only
temporary. Any attempt to break off the treatment at this point leads
to a marked worsening of the symptoms.

The handling of the transference siniation is the major problem in
psychotherapy. The psychoanalyst, who himself has had a successful
personal analysis, is theoretically more able to carry out psychotherapy,
because he has had experience of working through a transference
situation. The counter transference raises difficulties for the therapist
because he may derive satisfaction from the love and affection which
he receives from the patient and this may make it difficult for him to
resolve the transference situation. It is well to remember that the aim
of psychotherapy is to treat the patient and not the therapist!

2. Psychoaimlysis. —

The Classical Technique . — ^The patient lies on a couch and is told to
‘ free associate’, while the analyst sits w-atching the patient. The analyst
is completely passive and merely exhorts the patient to let his thoughts
wander and say everytUng which comes into his mind without hesita-
tion. Despite the protestations of the psychoanalysts there is no doubt
that the patient ts encouraged to produce certsdn types of material
which fit in with the analyst’s preconceived ideas. Changes in the
analyst’s breathing, the ^vay in which he says an encouraging word, or
the way in which he fidgets, can all influence the patient’s line of
thought although the analyst is unaware of doing so.

2i6

AN OUTLINE OP PSTCIIIATRY

A psychoanalytic session lasts one hour, and five sessions arc carried
out each week. In Britain the standard cost per session is three {^ineas.
As the treatment lasts several years it is beyond the reach of most
neurotics. In theory the most suitable cases for psychoanalysis are
young patients under 40 years of age, with, an acute neurosis with
little or no secondary gain and no marked character disorder. In fact,
what really determines whether a patient is taken on for psychoanalysts
is his ability to pay for this very expensive treatment.

Modified Techniques . — Some analysts have attempted to shorten the
treatment by giving the patient psychoanalytic explanations of his
s3'mptoms. This is fro\vned on by the purists, who point out that the
interpretations given to the patient arc really a form of suggestion.
They seem to be worried that the patient may be cured b)' the wrong
technique.

Jun^ian Analysis . — This is usually carried out facc-to-face and the
analyst plays a more active part than the Freudian analyst.

3. Group Therapy. — ftlany different forms of group therapy can
be organized. On the one hand, there are the large activity groups in
mental hospitals in which the patients are given didactic instructions
and cany out simple group activities; while, on the other band, there
are small groups of six to eight neurotic patients led by a psycho*
analytically trained therapist who helps the patients to analyse them*
selves in the group situation. The members of the small intensive
psychotherapy groups roust be chosen with care. They should be of
roughly the same social class, have the same cultural background, and
suffer from fairly similar psychological disorders. It is important not
to include someone who is in any way radically different from the
other members of the group, because he is liable to become the scape-
goat. The group discusses the problems of its members under the
leadership of the therapist The amount of active intervention and
direction of the group by the therapist depends on his theoretical
concepts and on his personality.

Group therapy is very useful for patients who tend to act out their
difficulties, because they can leant to recognize and to modify their
behaviour in the social milieu provided by the group.

Psychodraroa is a form of group therapy in which the patients arc
allotted parts to play; by aedng they leam to understand and modify
their behaviour disorders.

4. Suggestion and Hypnosis.—

General Principles . — If the patient is no longer deriving much
primary or secondary gain from his symptoms then a direct attack on
the symptoms with suggestion or hypnosis will usually lead to an
improvement. If the patient is still in conflict then suggestion will

TREATMENT AND MANAGEMENT 217

fail and hypnosis may remove the symptoms and leave behind a severe
emotional disturbance.

Suggestion . — ^This can be carried out in many different ways, such
as by the administration of inert tablets, highly coloured medicines, or
mild electric shocks.

The Technique of Hypnosis . — ^Thc patient lies on a couch and is made
as comfortable as possible. The room should be dimly lit and reason-
ably quiet. The patient is told to focus on a pocket torch or the point
of a pencil, which is held about one inch above and three inches away
from the bridge of the nose. As it is fatiguing to keep the eyes in the
right position the patient soon develops a sense of fatigue in his eye
muscles and in particular in the Icvatores palpebrae. When the patient
fixes his eyes on the object the hypnotist begins to say repeatedly,
‘You are sleepy; you are feeling sleepy’, and a little later he adds the
words, ‘Your eyelids are heavy, you cannot keep your eyes open’.
These words are said in a soft persuasive voice or in a confident
domineering way, depending on the personality of the hypnotist. The
suggestion that die eyes are closing is repeated, and, as the eyelids
begin to droop, the words, ‘Your eyes are closing’ are repeated insist-
ently. Once the eyes close the hypnotist clinches the matter by suggest-
ing that the arm will rise up of its otvn accord. He does this by saying,
‘You are quite calm. As you lie there perfectly relaxed you feel your
right arm is becoming lighter than usual. It is feeling lighter; It is
rising up.* The words, ‘ It is feeling lighter; it is rising up’ are repeated,
and as soon as any movement begins the hypnotist becomes even more
insistent, saying, ‘It is rising up; you cannot stop it; it is rising up’,
and so on. Once the arm has become more or less vertical there is no
doubt that the patient is in a moderately deep hypnotic trance. The
patient is then told chat the arm is heavy and will sink back on to the
couch.

Hypnotic Treatment . — Once a trance has been induced it can be
used in the follmving ways: —

a. A hysterical symptom can be removed and the patient told that
when he recovers the symptom will have disappeared.

b. Unconscious memories can be recovered and used in psycho-
therapy.

c. The patient can be persuaded to re-Uve a traumatic experience,
i.e., he is abreacted.

d. Post-hypnotic suggestion can be made. The patient is told that
he vrill do something after recovery from the trance.

In order to bring the patient out of the trance the hypnotist tells him
that on the count of five he will wake up or that when the hypnotist
snaps his fingers he trill wake up.

2i8 an outline of psychiatry

The Value of Hypnotic Treatment . — Hypnosis may be useful as a
part of a general plan of f»ycbotfaerapy, but it must be used with
caution. It may be very useful to win a brcailiing space when the
patient is exiremely aitxioua and not accessible to psy^othcrapy. In
some psychosomatic disorders, such as bronchial asthma, anxie^
triggers off the psychosomatic disorder which in turn creates more
anxiety, thus producing a vicious drefe. In such a hypnosis may
produce relaxation, breaking the vidous circle, and leading to an
improvement in the psychosomatic disorder.

5. Narcoanalysis and Abreaction. — Intravenous injections of
thiopentone or sodium amylobarbitone have been used to obtain un*
consdous material which would otherwrise take a long time to emerge
wth ordinary psychotherapy. There is no particular value in this
technique but it may be useful because it gives the patient an excuse
to produce material of which he is ashamed. These drugs arc sometimes
called ‘truth drugs’, but what a patient says when under the influence
of barbiturates is not necessarily true. Oespite the old tag tn vino
verilOJ, every barman knows that drunk men can liel

This use of intravenous barbiturates to recover unconscious memories
was at one time called ‘ narcoanalysis' and may be useful when a patient
Is unable to talk freely during psychotherapy. Apart from this these
drugs can also be used in abreaction, when the patient is persuaded to
redive a traumatic experience. Abreaction can also be induced by
hypnosis, the intravenous injection of 10-30 mg. of methylamphct-
amine hydrochloride (methedrine),or the inhalation of small quantities of
ether. In theory the patient is bring disturbed by the pent-up emotions
associated trith the traumatic experience, so that if he re-Iivcs the event
with a full expression of the assodated emotions he will be cured.

Abreaction is the treatment of choice in acute anxiety states caused
by a terrifying experience in which the patient’s life has been threatened.
Such experiences arc common in warfare, but are relatively infrequent
in dvilian life w-here, even if tbej' do occur, they are often complicated
by the possibility of compensation. Abreaction can also be used as a
variety of suggestion, when the patient is told that the re-living of
certain experiences will bring about a cure.

6. LSD Therapy. — Small doses of Ij’sergic add diethylamide
fLSD) produce a transient ronfudonal psychosis during which
unconscious memories may emerge. This drug has therefore been
used to obtain rapid access to unconsdous material which can then be
used in psychotherapy. The exact ii^aluc of this type of treatment is
not yet certain.

7. Relaxation Therapy. — Some tense and anxious patients benefit
considerably from learning to relax. The therapeutic effect of relaxa-
tion comes from the breaking of the vidous drcle of anxiety, leading

TREATMENT AND MANAGEMENT 219

to muscular tension, leading to further anxiety, and so on. Apart from
teaching patients general schemes of relaxation which lower the general
level of tension, patients can be taught to relax in very stressful situa-
tions. There are two main methods of relaxation: that of Jacobson and
that of Schulz.

In the Jacobson method the patient is taught to relax one group of
muscles at a time until he is able to relax them all. In the Schulz
method the patient learns to control his voluntary and involuntary
muscles by concentrating on certain thoughts. For example, 'he is
taught to relax his voluntary muscles by concentrating on the thought
that hia body is becoming heavy. This method is also called ‘auto-
genous training’.

8. Behaviour Therapy. — This is the application of learning theory
to psychotherapy. The fundamental idea is that neurotic behaviour is
made up of learned patterns of behaviour which must be modified by
the treatment process. Sometimes the therapy is very simple, as, for
example, in the treatment of nocturnal enuresis, in which there is no
organic cause. Here the patient sleeps on two tinfoil sheets which are
placed under the bed sheet. The upper tinfoil sheet is perforated and
is separated from the lower one by a thin cotton sheet. As soon as the
patient wets the bed the two tinfoil sheets are connected electrically by
the wet cotton sheet; a circuit is completed which trips a relay, which in
turn rings a bell and wakes the patient up. The tension in the bladder
at which nocturnal enuresis usually occurs becomes associated with the
bell and vraking up. After a few weeks the patient learns to wake up
when the pressure in his bladder reaches the point at which enuresis
usually occurred,*

In other disorders, aversive stimuli such as electrical shocks or
chemically induced nausea are assodated with the undesirable
behaviour pattern. This technique has been used for many years in
the treatment of alcohol addiction. More recently it has been applied
to the treatment of sexual perversions. Freund in Prague treated male
homosexuals by making them vomit while they were looking at photo-
graphs of naked men and making them sexually excited with test-
osterone when they were looking at photographs of nude women.

Wolpe has introduced ‘psychotherapy by reciprocal inhibition’.
The basic idea is that an anxiety response will be diminished if another
more satisfying response Is also present when the anxiety occurs. This
technique is particularly valuable in the treatment of phobic states.
The patient is taught to relax and then a hierarchy of stressors is worked

* These machines are marketed in the United Kingdom by Down Bros, and
Mayer & Phelps, Church Path, Itlitcham, Surrey, and by the Enurex Company
Ltd., Dryden Chambers, 119 Oxford St., London, W.i.

220 AN OUTLINE OF rSVCHlATRV

out, SO that there is a graded series of situations knowTi to the therapist,
which produce little anxiety, some anxiety, and so on to maximum
anxiety. 'Fhe situations which produce least anxiety is taken first and
the patient is encouraged to relive it. As soon as aiwiety appears the
patient is told to relax. A recent modification of this technique is the
use of methohexitonc sodium (brietal sodium) as a relaxant One ml. of
a 1 per cent solution of this drug is injected as soon as the patient
becomes anxious when he is thinking about a stressful situation. After
each injection the patient is encouraged to relax and the therapist waits
I minute during whicli he continues to tell the patient to relax. Then
the patient is persuaded to relive the anxiety-provoking situation and
given I ml. of t per cent methohexltone sodium as soon as anxiety
occurs. This procedure is repealed ten times in one treatment session.
Methohexltone sodium produces a pleasant relaxation which wears off
fairly quickly because the drug is rapidly broken down in the body.
This treatment can be used in the outpatient clinic, but patients should
be advised not to drive a motor-car within a few hours of the treatment.

In general, behaviour therapy is very suitable for the treatment of
National Health Service patients. In psychoanalj-sU and psycho-
therapy in private practice the patient « motivated to get better by the
fact that he is paying the therapist large sums of money as long as he
is having treatment. The National Jiealth Service patient receiving
deep psychotherapy has no such motivation and may for years live in a
pleasant psychological symbiosis xvith his therapist Behaviour therapy
is not a pleasant form of treatment because the patient is given aversive
stimuli or forced to relive anxiety-provoking situations. The patient
is, therefore, motivated to get better.

9. Practical Short-term Psychotherapy. — ^\Vith the exception of
psychoanalysis nearly all of the techniques so far described can be used
in short-term psychotherapy, which aims at producing a, substantial
improvement in the patient’s condition within s period of six montlis.
The treatment which will be outlined can only be used in patients with
average and superior intelligence, who are sufficiently sophisticated to
accept the idea that some illnesses arc psychologically determined and
can be cured with psychological treatment. In simple-minded and
dull patients one has to rely on a mixture of firm reassurance, simple
explanation of symptoms, cnwroruncntal manipulation, and suggestion.

Defining the Problem . — ^The first step is to determine the precise
reason which has brought the patient to ask for help. This can only be
done as a result of a few careful preliminary exploratory intcnTcws
with the patient and his relatives.

Establishing the Fasts. — A dear account of the patient’s personality,
symptoms, and environmental difficulties must be made from informa-
tion derived from ail possible sources. In psychoanalysis the patient’s

TREATMENT AND MANAGEMENT 221

own evaluation of himself and his environment, so-called ‘psychic
reality’, is accepted by the therapist. In short-term eclectic psycho-
therapy it is essential for the therapist to know the real situation,
because he must help the patient to make the best possible adjustment
in the shortest possible time.

It is important not to allow anxiety symptoms due to a real-life
difficulty to be turned Into an illness. In such circumstances the
patient must be told that his nervous upset is the natural ronsequence
of his situation and will improve when his personal difficulties are
resolved. In marital disharmony it is quite common for one of the
partners to turn his or her natural unhappiness into an illness, which
is then used as a weapon against the spouse.

The Role of the Penonality in the Illness . — The therapist must always
try to answer Clouston’s first question, ‘What sort of man was this
when he was reckoned well in mind ?’ One must get a clear idea of the
patient's previous personality in order to distinguish between the symp-
toms which are new and those that are exaggerations of long-standing
anomalies of the personality. It may be necessary to explain to the
patient that he has an abnormal personality In Schneider’s sense {see
p. 67) and that he must recognize the weak spots in his personality,
so that he can avoid putting himself in stressful situations. This is
particularly important in ‘episodic psychopaths’ who manage to get
themselves into difficulties from time to time. It may be necessary to
persuade the patient to tolerate certain abnormal personality traits in
the same way in which one has to tolerate minor physical deformities
such as a large nose or an asymmetrical face.

General Psycho-patkalagical Explanations . — The patient should be
given a simple explanation of the psychological causation of the illness.
The first step is to explain unconscious mental activity. This can be
done by saying to the patient something like the following: ‘The mind
is like an iceberg, and, as you know, one-third of an iceberg is above
the water and two-thirds are underneath. A great part of our feelings
and thoughts is unconscious and cannot be brought into consciousness
very easily. If one has a problem which is difficult to solve it may be
put in cold storage and pushed into the unconscious mind. If this
happens one rs no longer aware of the problem, but it still has an effect
on the conscious mind in an indirect way, because it produces anxiety
and other psycholopcal disturbances of the conscious mind.’ The
patient should be given a simple psychological and physiological
explanation of his symptoms at the outset of the treatment. If he has
somatic symptoms of anxiety he should be asked to try to remember
how he felt in the past when he was frightened. It is then explained
to him that anxiety is fear for no reason and that his ph^’sical symptoms

222 AN OUTLINE OF PSYCHIATRY

are the result of a constant state of fc2i. As the psjxholhcrapy proceeds
the therapist uses tlie matertal wfiidi emerges to illustrate the mental
mechanisms {see p. 27) •which are involved.

Pulling the Onus on the PatienL — Once it is decided to begin psycho-
therapy it is important to be sure that the patient accepts his illness
as being psychological and that he realizes that psychotherapy airrm at
helping him to help himself. He must never be allowed to forget that
psychotherapy is a joint effort by the patient and the therapist. It is
alw ays important for the therapist not to allow himself to be forced
into a position where he is maldng decisions for the patient. IVhenevcr
the patient asks the question, *\Vhat should I do ?' the therapist must
reply, ‘MTiat do you think you should do ? lyct us discuss all the pros
and cons and then you must make up your mind.'

Setting the GoaU to be Achieved . — ^At the end of the preliminary
exploratory intenuews the therapist decides that there are several areas
of conflict and ranks them in order of importance. He begins treatment
by discussing what seems to be the most important area of conflict.
Hlien the patient has gained reasonabie insight into his problems in
this area then the next most important topic is dealt with. As the
treaUnent proceeds new information emerges which may lead the
therapist to modify his initial ideas about the nature and importance
of the diflerent areas of conflict.

Resislanee.—Tht patient may refuse to deal with anything except
trivialities or he may say very little during the intervietia. This is
resistance and is produced by an unconscious wish to retain the neurotic
symptoms because this appears to be the least stressful solution of the
conflict. The nature of the rc^stance must be pointed out to the
patient and may be overcome by persistence on the part of the therapist.
Sometimes it may be necessary to direct the discussion away from a
painful topic and then to approach the topic more obliquely. Another
method of overcoming resbiancc is abreaction \7ith ether, intravenous
methylamphetamine, or sodium amylobarbitone.

Another less obvious form of resistance is the production of large
amounts of interesting sexual material that coi^orms nicely Avith
psychoanalytic theory. The therapist may unwittingly be deflected
from his task and devote many sessions to fascinating psychoanalytical!}
orientated discussions that are entirely beside the point.

Social and Environmental Changes . — During psychotherapy it may
become obrious that the patient should make changes in his environ-
ment, such as changing his job, jewing a club, or altering his domestic
arrangements. Once the patient decides to make such a change the
therapist must help him to carry it out.

Consolidating ihe Insight . — ^The patient is usually seen once a week
for one hour. At the end of each interview the therapist summarizes

TREATMENT AND MANAGEMENT 223

what has been learned in the session. The patient is then asked to
repeat this and tlie therapist makes any necessary corrections.

At the beginning of the next interview the patient is asked to explain
what he has learned at the previous one. The therapist corrects any
mistakes and then asks the patient to repeat the corrected version.

Periodic Retieto of Progreu, — ^Eveiy six weeks the therapist reviews
the progress so far and decides on strategy for the next six weeks.
One session is devoted entirely to a discussion of the patient’s under-
standing of his illness.

At the end of six months the case is reviewed in detail and one of
the following decisions is made; —

1. To continue psychotherapy for a further limited period of three
or six months.

2. To discharge the patient as cured, improved, or unlikely to
benefit from further treatment.

3. To transfer the patient to supportive psychotherapy.

Supportive Psychotherapy. — Some patients, particularly obsessional

neurotics, seem to be helped by half-hour interviews every few weeks.
The patient gets relief from being able to talk about his symptoms to a
sympathetic listener who can reassure him. This supportive psycho-
therapy should, where possible, be carried out in evening clinics so
that the patient does not lose woik.

Th$ Use of Drugs in Psychotherapy — ^Drugs may be used at the same
time as the patient is receiving psychotherapy, but it must be made
clear to the patient that the drug is merely a crutch and not a cure.
Thus if anxiety is severe the patient may be given a sedative to allay
the disturbance and allow the psychotherapy to get under way. The
sedative should be given for a limited period so that the patient does
not become habituated. Similarly, in the treatment of the perversions
the libido may be suppressed with oestrogens or thioridazine in order
to keep the patient out of temptation during the early weeks of treat-
ment.

224

CHAPTER XV

PSYCHIATRY AND THE LAW

ENGUSH AND SCOTTISH LAW IN RELATION TO
PATIENTS

X. The Statutory Bodies. — ^\^arious bodies have legal obligations
under the Mental Health Act, 1959, and the Mental Health (Scotland)
Act, 1960. They are: —

a. The Loeal Health Authority . — ^This is the Public Health Depart-
ment of the Count)' Boraugfa, County, or Burgh Council. It has the
follotvmg responsibilities: —

J. The provision of residential accommodation for mentally-iJl
patients not neediog hospital care.

ii. In England, the provision of centres or facilities for training and
occupation of the mentally handicapped living in the community.

iii. Duties in connexion tvith guardianship procedures under the
Acts.

iv. The appointment of mental welfare officers (England) or mental
health officers (Scotland) to carry out duties in connexion t^ith its
responsibilities. In Scotland these officers also have the duty of ascer-
taining mental defect in persons not of school age and are responsible
for the supervision of mental defectives not in hospital or subject to
guardianship,

b. Regional Hospital Boards and Hospital Management Committees , —
These are responsible for the maintenance of hospitals within a given
region of Britan. The immediate administration of the mental hospital
is the function of a hospital management committee, a board of
governors or, in Scotland, a board of management.

e. Mental Health Reoieso Tribunals {England ). — ^These regional
tribunals are appointed by the Lord Clmccllor to hear appeals by
patients or their relatives against the patient’s detention in a hospital.
Members of these bodies must be lawyers, doctors, or individuals m'th
spedal experience in administration and sodal services, and the chair-
man must be one of the legal members,

<f. The Mental li'etfare Cosmstistwm (Seo(lanif ). — This is a body
composed of seven to nine commissioners, of whom at least one must
be a woman, three must be doctors, and one a lawyer. They arc

PSYCHIATRY AND THE LAW

225

responsible for visiting mental hospitab of all kinds, for investigating
complaints of illegal detention, and for the general protection of the
mentally ill.

2. Definitions of Mental Disorder. —

a. Scotland. — ‘Mental illness or mental deficiency however caused
or manifested. ’

b. England, — ‘Mental illness, arrested or incomplete development
of mind, psychopathic disorder, and any other disorder or disability of
mind. ’

Severe subnormality: ‘A state of arrested or incomplete development
of mind which includes subnormality of intelligence and is of such a
nature or degree that the patient is incapable of living an independent
life or of guarding himself against serious exploitation, or will be so
incapable when of an age to do so.’

Subnormaltty: ‘A state of arrested or incomplete development of
mind (not amounting to severe subnormality) which includes sub-
normality of intelligence and is of a nature or degree which requires or
is susceptible to medical treatment or other special care or tr^ning of
the patient. ’

Psychopathic disorder: ‘A persistent disorder or disability of mind
(whether or not including subnormality of intelligence) which results
In abnormally aggressive or seriously irresponsible conduct on the part
of the patient, and requires or is susceptible to medical treatment.'

The Act goes on to point out that promiscuity or immoral conduct
is not in itself an indication of mental disorder which can be dealt with
under this Act.

3. Admission Procedures. —

a. Informal Admission. — The aim of both Acts is to encourage
admission to hospital for mental illness in the same way as admission
for physical illness.

b. Removal to a Place of Safety. — Both Acts allow a constable to
remove a mentally disordered person found in a public place to a
‘place of safety’. A neglected mentally iU person can be removed
forcibly from enclosed premises if need be by a warrant issued by a
Justice of the Peace. Detention in a 'place of safety* cannot exceed
seventy-two hours.

c. Observation. — One of the outstanding weaknesses of the Scottish
law is the absence of any observation procedure. Section 25 of the
English Act allows the detenrion of a patient for observation for not
longer than twenty-eight days. Application for admission is made by
the mental welfare officer or relative to the managers of the hospital,
supported by written recommendations of ttvo doctors, including a
statement that, in the opinion of each doctor: —

i. The patient is sulTering from a mental disorder which warrants his
detention in a hospital for observation for a limited period.

ii. The patient ought to be det^ed in the interests of his own
health or safety or with a iriew to the protection of others. Under
section 29 of the Act this procedure can be used for emergency admis-
sion. Application for admission is made by the mental welfare officer
or relative and one medical recommendation conforming to section 25 is
made. The patient can be detained for seventy-two hours, during which
the second medical recommendation can be made or other action taken.

d. Compulsory Admission to Ilospilol {Recommended Patients ). —
Section 26 of the English Act and section 24 of the Scottish Act allow
the compulsory admission of a patienc Application must be made by
a relative, a mental welfare officer, or a mental health officer, and must
be supported by two written recommendations by doctors. In Scot-
land the application has to be approved by a Sheriff (a stipendiary
magistrate).

\ATicre it is difficult to complete the recommendation procedure and
admission is urgent, section 31 of the Scottish Act allows an urgent
recommendation by a doctor to detain a patient in hospital for a
maximum period of seven dap, during which the rest of the recom-
mendation procedure under section 24 should be carried out. Applica-
tion for urgent admission can be made in the case of a patient already in
hospital, 80 that an informal patient can be detained under this section
if his discharge is not advisable.

In the English Act the application must be made by the nearest
relative or with his consent. If the patient needs to be admitted compul-
sorily and the nearest relative refuses to make the application, then the
mental welfare officer, another relative, or a person with whom the
patient is residing may apply to a County Court to be given the powers
of the nearest relative which will enable him to make the application
under section 26.

In Scottish Law the relative may object to the Sheriff, who has the
power to inquire into the circumstances and take evidence on oath
from all the parties concerned.

Under section 26 of the English Act the reasons for an application
are as follows: —

i. The patient is suffering from mental disorder, being: —

In the ease of a patient of my age'. Mental illness or severe sub-
normality.

In ike ease of a patient under 21 years of age: Psychopathic disorder
or subrvannallty, and that the (Usntdec U of a nature or degree
which warrants the detention of the patient in a hospital for medical
treatment under this section.

PSYCHIATRY AND THE LAW 227

ii. That it is necessary in the interests of the patient’s health or
safety or for the protection of others that the patient should be so
detained.

The medical recommendations must state that these conditions have
been complied with.

Under section 24 of the Scottish Act the medical recommendations
must include the following statements and the reasons for the state-
ments: —

i. A statement of the form of mental disorder from which the patient
is suffering, being mental illness, or mental deficiency, or both.

ii. A statement that the said disorder requires or is susceptible to
medical treatment and is of the nature or degree which warrants the
patient’s detention in a hospital for such treatment.

iii. A statement that the interests of the health or safety of the
patient or the protection of other persons cannot be secured otherwise
than by such detention as aforesaid.

The authority for the detention of the patient can be renewed at the
end of the first year, the second year, and thereafter at 2-yearly intervals.
In England this is done by the responsible medical officer examining
the patient within the last two months of the period of detention and
reporting to the managers of the hospital that it is necessary for the
patient to continue to be detained. In Scotland a similar report must
be given to the board of management of the hospital and the Mental
Welfare Commission.

e. Medical Recommendalims . — These must be signed on or before
the date of application, and must be given by doctors who have
personally examined the patient together or at an interval of not more
than seven days.

One of the doctors should have special experience in psychiatry and
be approved by the local health authority in England or the regional
board in Scotland, The other, if possible, should be the family doctor
or another doctor who is acquainted with the patient.

Except where the patient is to be admitted to private accommodation
one of the recommendations can be made by a doctor on the staff of
the mental hospital which will receive the patient.

In England a medical recommendation cannot be given by the
applicant, a partner or assistant of riic applicant, or by a partner or
assistant of the doctor who has given the other recommendation, or by
anyone who receives money /or the maintenance of tbe patient, or
by a relative of the applicant or the other doctor.

4. Guardianship. — Some mental defectives and mentally ill patients
can be looked after in the communi^ if someone is responsible for
them. In Scotland mentally defective patients have been ‘ boarded out’

for many years. This can now be done by application for guardianship.
In both England and Scotland the procedure for guardianship is more
or less the same as that for recommended admission. The guardian can
be the local authoriQf or a person approved of or nominated by the
authority.

5. The Protection of PattcDt*s Property. — ^VVhere someone is
unable to manage his affairs it is essential that some disinterested party
be appointed to do 50. This applies to all persons wth mental illness
whether in hospital or not. The person a>ncerned need not be certifi-
ably insane. It is important to explain to the relatives that the legal
procedure has nothing whatsoever to do with certification.

Procedure ttt England. — Application « made to the Chief Clerk,
Court of Protection, Store Street, London, W.C.i. Tlie Court requires
a certificate or affidavit from Uie family doctor or the responsible
medical officer, which states that the person concerned is incapable,
by reason of mental disorder, of managing and administering his
property and affairs.

A judge of the Court of Protection may give instructions for the use
of the patient’s income to mainudn him, his family, or other persons
normally supported by him. Usually a receiver is appointed to manage
the patient's affairs. This may be a solicitor or an accountant, or, if
the patient is in hospital, it may be the secretary of the hospital.

F^ocedure tn Scotland. — A enrafor^mV or judicial factor is appointed,
following a petition to the Junior Lord Ordinary of the Court of Session.
If the estate does not exceed £100 per annum application cart be made
in the Sheriff Court. A solicitor or chartered accountant is usually
appointed curator bonis. The petition to the Court has to be supported
by two medical certificates given *on soul and consaence* that the
patient is, owing to his mental state, unable to manage bis own affairs
or unable to give instructions to others for their management.

MENTAL ILLNESS AND THE CIVIL LAW

Legsil Responsibility In Ovil Law. — In general, mental disorder
prevents a person giving evidence under oath, but a judge may decide
that a given patient can do so, and the jury may then be obliged to
determine what credence should be pven to such evidence.

A person of unsound mind cannot make a valid contract because the
law supposes that in making a contract there is a full and free consent
of the contracting parties, whidi presupposes an act of reason of which
the mentally sick person is incapable.

TestBsaesstasy Capacity, — ^The foUmving two points should be
noted: —

I. A will is not valid if it is made by a person under 2 i years of age
or by an adult idiot, imbeale, or feeble-minded person.

PSYCHIATRY AND THE LAW 229

2. A person of unsound mind, whrther certified or not and whether
in hospital or not, can make a valid will providing that it can be shown
that at the time of doing so he had a ‘sound disposing mind’.

Essential Conditions for Testamtntary Capacity. — ^\Vhen asked to see
a patient in connexion with his fitness to make a will the doctor should
satisfy himself that the patient: (i) Is able to understand the nature
and consequences of his act, i.e., that he is making a will to dispose of
his property after death; (2) Knows the nature and extent of his
property; (3) Is able to enumerate all those persons who are the natural
objects of his charity; (4) Is able to give a good reason if he excludes
from his will someone who is a natural object of his charity; {5) Has
no insane delusions or suspidons about his relatives which would
influence his judgement; (6) Is able to recapitulate his will mth reason-
able accuracy.

Points to he Rememhered by the Doctor , —

1. A full psychiatric examination should be carried out with no one
else present.

2. A full history and all relevant facts should be obtained from one
or more relatives.

3. Full details of the patient's estate and his relatives and dependants
should be obtained from the patient’s legal adviser.

4. Great care should be t^en and, if necessary, a second opinion
should be sought if: (a) Aphasia is present; (&) There is gross memory
loss; (c) The patient is under the influence of drugs; (d) The patient
is being unduly influenced by any person.

5. It is essential to take full notes, including verbatim notes of the
most crucial points.

Marriage and Divorce. — The Matrimonial Causes Act, 1965, and
the corresponding Scottish Act allow insanity as a ground for nullity
and divorce.

Nullity. — If either party to the marriage is at the time of the marriage
of unsound mind or a mental defective, or subject to recurrent fits of
insanity or epilepsy, the marriage is voidable as long as: (i) At the
time of the marriage the petitionerdid not know the facts; (2) Proceed-
ings are begun within a year of the date of the marriage; (3) Since the
discovery of the grounds for a decree of nullity the petitioner has not
consented to sexual intercourse with the partner.

Divorce. — A petition for divorce may be presented by either partner
on the grounds that the respondent is incurably of unsound mind and
has been continuously under care and treatment for a period of at least
five years preceding the presentation of the petition. ‘ Continuously
under care and treatment’ means that continuous mental hospital care
for five years without a break has been necessary. ‘ Incurably of un-
sound mind’ means that there is no chance of the patient recovering

ZJO AN OUTLINE OF PSYCHIATRY

to such a degree that he would be able to undertake the ordinary duties
of marriage.

CRIMINAL RESPONSIBILITY

Minor Crimes. — ^The Criminal Justice Act, 1948, and the Criminal
Justice Act (Scotland), 1949, allow a Magistrate’s or Sheriff Court to
make in-patient or out-patient treatment a condition of aprobation order.
Section to of the English Mental Health Act, 1959, and section 55 of the
Scottish Act, i960, allow the Courts to make an order for the admission
to a mental hospital of someone convicted of a crime punishable by
imprisonment. This can be done if the Court is satished with the
wTitten or oral evidence of ttvo doaors that the offender has a mental
disorder of such a nature or degree which warrants hospital treatment.
The Court can also restrict the powers of discharge from hospital.

Offenders reminded for trial can be ojmmitted to s mental hospital
for the period of remand, as long as this course is recommended by a
doctor.

Capital Crimes.—In minor crimes insanity is rarely rabed as a
defence, because the offender realizes that this might involve a long
period of detention in hospital instead of a short prison sentence.
Problems of criminal responsibili^ are really only of importance legally
in countries where the perulty for murder is death. In Britain the
offender may be found to be insane before the trial, as a result of the
trial, or after the trial.

Vnjitnsu to Plead . — In order to be fit to plead the accused must be
able to: (t) Understand the nature of the charge; (a) Challenge a Juror;

(3) Know the difference between a pica of ‘guilty* and ‘not guilty';

(4) Follow the evidence; (5) Instruct his legal advisers.

There is a difference in opiruon on the fitness to plead of a mentally
ill person. Some hold that wherever possible the accused should be
found fit to plead, because otherwise an insane innocent person might
be detained as a 'Broadmoor patient’ (the modem English tenn for a
criminal lunatic) and have less civil rights than a recommended patient.
The other vie^v is that to subject a mentally ill person to a criminal
trial is unfair and the patient must be to some degree unable to con-
form to the criteria set out above. This difference is reflected in the
statistics for insane murderers in England and Scotland. Thus from
1900 to 1948 in England 412 persons charged with murder were found to
he insane on arraignment and 783 guilty but insane. The corresponding
figures for Scotland were J04 and *3 respectively, ^^'hen a person is
found unfit to plead he is detained *at Her Majesty’s pleasure’ in a
State or ordinary mental hosjntal.

Guilty hut lusaru . — In En^nd for many years the conditions for
the defence of ‘guilty but insane* have been embodied in the opinion

PSYCHIATRY AND THE LAW 231

given by the Law Lords following the McNaghten trial and known as
the McNaghten Rules. The relevant parts of these rules are: —

1. In order to establish a defence on the ground of insanity it must be proved
that at the time of committing the act the party accused was labouring under
such a defect of reason from disease of the mind as not to know the nature and
quality of the act he v>as doing, or if he did know it, that he did not know that
tvhat he was domg was wrong.

2. If the accused labours under ‘partial delusions’ only and is in all other
respects sane, he should be considered in the same situation as to responsibility
as if the facts with respect to which the delusion exists were real.

These rules have been applied In all subsequent judgments in
England and have influenced legal practice in many English-speaking
countries. On the whole, they have been interpreted fairly liberally
in the English Courts. Unfortunately, they do not cover all insane
murderers, particularly the depressive parents who murder their
children.

However, it is unusual for an insane murderer to hang, because the
Home Secretary or the Secretary of State for Scotland has an obliga-
tion, under the Criminal Lunatics Act, 1884, to investigate the mental
state of a condemned person in whom the possibility of insanity has
been raised. Should a majority of experts who examine the condemned
person report that he is insane then a reprieve is recommended and he
is detained at Her Majesty’s pleasure.

Diminished Responsilfility . — In Scotland, where most insane mur-
derers are found unfit to plead, those that do stand trial can plead
partial responsibility. This was expressed by Lord Alness as follows: —

There must be some aberration or weakness of mind ; there must be a state
of mind bordering on, though not amounting to, insanity; there must be a mind
so affected that responsibility is diminished from full responsibility to partial
responsibility; the prisoner m question must be only partially responsible for
hts action.

If the plea of partial responsibility is accepted the charge is reduced
to culpable honucide, which carries a sentence of up to ten years'
imprisonment, so that a potentially dangerous man is removed from
society for a limited period. An indetcnrunate sentence would be a
better solution.

The Homicide Act, 1957, introduced this concept of partial respon-
sibility into English Law. Section 2 of this Act states: —

Where a person kills or is party to a killing of another, he shall not be con-
victed of murder if he was suffering from such abnormality of mind (whether
arising from a condition of arrested or retarded development of mind or any
inherent causes or induced by disease or mjury) as substantially impaired his
mental responsibility for his acts and omissions in doing or being a party to
the killing.

232 AN OUTLINE OF PSYCIUATRY

If the plea of diminished rcsponabillty is accepted the charge is
reduced to manslaughter, uhich can lead to a sentence of many years’
imprisonment, after which the individual will be free.

AVhile it must be granted that the Scottish concept of partial respon-
sibility is humane and avoids such judicial farces as the trial and
hanging of a schizophrenic murderer,* it does not deal adequately
with the grossly unstable psychopathic murderer, who may Jiave to be
kept away from society for the rest of his life.

Infanticide . — The Infanticide Act, *938, recognizes that within
twelve months of the birth of a child the balance of the mind may be
disturbed fay exhaustion due to childbirth or the effects of lactation.
Thus, any woman who causes the death of her child under the age of
12 mont^ is usually charged with infanticide and convicted of man-
slaughter.

GENERAL POINTS ON PSYCHIATRY AND THE LAW

Contradictory Psychiatric Evidence.— The Law is often asking
questions which require a definite reply. Unfortunately, in science and
in medicine, there are many areas where it is impossible to give a clear-
cut answer, and to do so w-ould be dishonest. If an expert witness gives
an indefinite answer his testimony is bound to be compared unfavour-
ably with the clear negative and positive answers given by another
expert witness, whose confident assertions may be based more on
ignorance than superior knowledge.

Much of the confilct of p^chlatric evidence in murder trials in
England was due to the fact that the murderer would probably hang if
found guilty, which led the defence to put forward a plea of insanity
if tlicre was no other really adequate defence. It would appear that
psychiatrists who did not agree with capital punishment could often be
prevailed upon to give evidence in support of insanity in these cases.

Psychopathology and Psychodynaralcs In Evidence. — Psycho-
pathological and psychodynamic formulations arc very useful in treating
patients who come to the doctor wanting to be cured of a neurotic
condition. They should, however, not be used as excuses for criminal
behaviour, carried out by persons who are unwilling to face the conse-
quences of their immoral acts.

^^'hcn a patient who is troubled and wants to be helped says that he
cannot remember some event, one assumes that this memory is un-
conscious, although it often subsequently transpires that this w« a
convenient fiction. However, when a criminal claims that he has no

• It is scarcely credible, but none the less true, that Rivett, nhoat least t»o
prison medical officers and one psychiatric specialist testified was inianc, was
in fact hanged in England in 1950.

PSYCHIATRY AND THE LAW 233

memory of a violent crime this can only be accepted if there is evidence
that he was suffering from some o^amc disorder which caused the
amnesia. Hysterical amnesia is a charitable concession made in the
consulting room, but is no defence in a criminal trial.

ABORTION

The law on the therapeutic tennlnation of pregnancy has been
substantially changed by the Abortion Act of 1967, «hich applies to
England, Wales, and Scotland. It is now legal to terminate a pregnancy
if two registered medical practitioners are of the opinion: —

'(a) that the continuance of the pregnancy would involve risk to the
life of the pregnant woman, or of injury to the physical or mental
health of the pregnant woman or any existing children of her family,
greater than if the pregnancy were terminated; or

‘(b) that there is a substantial risk that if the child were bom it
would suffer from such physical or mental abnormalities as to be
seriously handicapped'.

The Act goes on to say that in detemuning the risk to the patient
‘ account may be taken of the pregnant woman’s actual or reasonably
forseeable environment’.

This Act is a great step fortvard as it allows the total social, psycho*
logical, and medical background of the patient to be taken into account
when deciding on a therapeutic abortion.

THE PSYCHIATRIC ASPECTS OF MURDER

1. Murder in England in Recent Years. — The murder rate in
England in the recent past has been about 3 per million inhabitants
per year. There has been a slight increase in the rate in recent years
but this is negligible compared with the marked increase in crimes of
violence in the same period. Almost one-third of murderers in England
commit suicide and of those who are brought to trial nearly 50 per
cent are found guilty but insane. Most child victims of murder are
killed by their parents, and just over two-thirds of the adult female
victims are killed by their husbands, relatives, or associates.

It seems that depression (autonomous d}’sthymia) and psychogenic
reactions taking the form of depression are common causes of murder
in England. It would appear that schizophrenia is not as common a
cause of murder as depression.

2. The Psychiatric State of Murderers. —

a. Depression {Autonomous Dysthymia ), — Murder can be regarded in
some cases as an extension of suicide. This particularly applies in
depression (autonomous dystbymia). Sometimes the hypochondriacal
delusions concern the patient’s children as well as his own body. He

234 an outline of PSYCHIATny

may believe that he has given them a foul incurable disease or that they
are doomed by heredit)' to the same incurable madness as he has. The
murder of the children is justified by the idea that it will relieve them
of their suffering. Depressed mothers, especially puerperal depres-
sives, have obsessional fears of killing their children. In general,
patients do not act on obsessions, but tlw obsessional fears of killing or
harming a loved one in depressives arc an exception to this rule. Once
a depressed patient expresses such fears he or she should be admitted
to hospital as an emergency. Sometimes homicide has a cathartic effect,
so that the depressed parent murders the child and the depression lifts.
This means that the parent may show* no signs of depression when
arrested. These depressed parents usually employ some simple homely
method of murder such as strangulation, beating the child on the head
with a coal hammer, drowning tn the bath, or coal-gas poisoning.

b. Psychogenic Jitactions in Umlable Indhiduah . — ^Tbese can also be
regarded as extended siuddes. The unstable unhappy person finds
himself in a difficult situation and can see no way out. He murders
his loved one and then commits suicide. The murder and suicide can
be regarded as a despairing Samson-Iike finale.

e. The Coialhymie CritU. — Gould has called this ‘the autonomous
affective crisis of adolescence*. These murderers are unstable male
adolescents who have had disturbed relationships with their parents
from childhood. They murder the mother, both parents, or a parent
surrogate. Sometimes a quantity of alcohol not suffident to produce
drunkenness is taken before the murder.

d. Schisophrenia. — ^The importance of this illness as a cause of
murder depends on the diagnostic criteria for schizophrenia. Many of
the murderers in groups ( 5 ) and (r) above have grossly abnormal
personalities and would be diagnosed as schizophrenic by some psychi-
atrists, espedally in the United States.

e. Motiveless Murders.- — Some ^gressive psychopaths commit mur-
der for no reason, or in response to a trivial upset. Stafford Clark and
Taylor found that 73 per cent of moti^'elcss murderers had abnormal
electro-encephalograms.

/. The Apex Murder. — Here the murder is a culmination of a career
of delinquency. The individual's delinquent behadour worsens until
finally he commits murder, often for little reason and usually by
shooting.

g. The Sexual Murderer. — Since sex and violent^ sell newspapers
sexual murders always receive the maximum publicity, although com-
pared with other murders they are relatively uncommon. The com-
monest sexual murder is the murder of a child or woman by a paedophil
or a rapist. Sometimes the murder is Mcidental and follows an attempt

PSYCHIATRY AND THE LAW 235

to Stifle the victim’s screams, while at other times it is an attempt to
aTOid recognition. However, in some cases the murder is an essential
part of the sexual act. A few sadistic murderers obtdn sexual pleasure
from murder and gross mutilation of the victim {see p. 173).

h. The Jealous Husband . — ^Apart from wounding, beating, and even
torturing their tvives some jealous husbands also murder them {see
p. 86).

i. Organic States . — The commonest coarse brain disease associated
with murder is epilepsy. Some epileptics are aggressive violent in-
dividuals who commit impulsive or motiveless murders.

THE PSYCHIATRY OF SUICIDE

Suicide is no longer a crime in England, but, as it has legal and
social implications and attempted suicide occurs in many different
psychiatric conditions, it is convenient to discuss it in this section,

1. Attempted Suicide. — Attempted suicides and successful suicides
form Uvo separate groups which overlap slightly.

The attempted suicide is usually carried out by an unstable individual,
often from a broken home, and not infrequently he attempts suicide
after drinking. At times the act is a frank attempt at manipulation, for
example, when a man attempts suicide outside the house where his
estranged wife is living. In marital disharmony when one partner tells
the other that the marriage is at an end the aggrieved partner usually
threatens suicide in an attempt to force the spouse to continue the
marriage, and in a few cases carries out this threat, usually unsuccess-
fully. Sometimes the manipulation is not so obvious, but Uie net effect
of die sutddal attempt is to bring the family and friends to the patient’s
aid. It is not easy to be certain whether this was the motive of the
attempt.

It is usual to estimate the seriousness of the suicidal attempt by
examimng the way in which it was organized and the steps taken to
avoid detection. However, a poorly organized attempt does not mean
that there was no serious suicidal intent. Many anxious patients
cannot think clearly, so that they are not able to attend thoroughly to
all the details of organization, although the desire for death is intense.

2. Successful Suicide. — As has already been pointed out many
murderers commit suicide and quite a number of these are depressed
in both senses of the word. Recently an investigation of successful
suicides has shown that there were clear indications of depression,
mainly autonomous dysthymia, in most cases before the suicide
occurred. Some attempted suicides are, of course, individuals who
would have been successful if thrir plans had not accidentally gone
awry. These patients make up most of that small proportion of
attempted suicides who Anally co mmi t suicide.

236 AN OUTLINE OF PSYCHIATRY

3. Psychiatric Causes of Suicide and Suicidal Attempts.—

a. Depression {Autonomous Dystkymia ). — All patients with this ill-
ness must be considered as suicidal lufcs. It is usually claimed that the
extent of self-reproach indicates the severity of the suicidal risk, but
this is not so. The risk of suicide is probably greater in patients with
paranoid depression and in those who have attempted suicide in a
previous illness. A broken home in childhood is the only feature
which distinguishes suicidal from other depressives.

b. Psychogenic Retutiem . — Suiddc is often the reaction of an un-
stable individual to a difficult environmental situation, often partly of
his o^vn making. The severity of the social difficulties and the ab-
normality of the personality vary from case to case, but show an inverse
relationship. Many of these patients could be called reactive depres-
sives, but they are not depressed in the sense of (o) above. They are, in
fact, unhappy people faced with problems which they cannot solve.
Most of these patients do not commit suicide, but some make repeated
suicidal attempts, and a few may kill themselves by accident. Some
grossly abnonnal personalities, particularly appreciation-needing
psychopaths, make repeated suicidal attempts in order to manipulate
the environment or to obtain attention.

e. Sehisophrenia , — Suicide may occur at any time in the course of
schizophrenia but it is commonest in the acute stage of the illness. In
chronic schizophrenia it tends to occur in the Leonhard non-systematic
varieties and in the milder systematic paranoid types.

d. Old Age.— Thi suicide rate in the Western world is highest in
old age. This is probably due to autonomous dysthjTnia, arterio-
sclerotic psychosis, and psychogenic reactions to sodal difficulties,
wluch are all fririy common in old age.

e. Organic Slates . — Some acutely confused patients in delirium may
jump out of windows in an attempt to escape from supposed perse-
cutors, but this is hardly suicide. On the whole, suicidal attempts arc
not common in acute organic states with the exception of those due to
epilepsy and arteriosclerosis.

In epilepsy depressed irritable moods (epileptic dysthymia) may
occur in which the patient attempts or commits suicide. A few tem-
poral lobe epileptics have ictal moods and may attempt suicide almost
immediately after the onset of an ictal depressive mood- Some epi-
leptics with marked personality change may react to the difficulties
caused by their fits and their personality by attempting suicide.

Arteriosclerotic dementia is often ushered in by a depression in
which the patient attempts suicide. As insight is preserved until a
fairly late stage of the illness, the suicidal risk is much greater than in
senile dementia or Alzheimer’s disease, where the patient is usually
blissfully unaware of his dedine.

PSYCHIATRT AND THE LAW 237

Suicide may occur at any stage in Huntington’s chorea and some-
times when the patient is extremely demented. No satisfactory explana-
tion has ever been put forward to explain why Huntington’s chorea
is the only chronic degenerative brain disease in which suicide is
common.

4 . Estimation of Suicidal Risk. — In any patient with depression
(autonomous dysthymia) questions must be asked about suicide and
if he expresses suicidal thoughts every attempt must be made to tvin
his confidence and to reassure him about the favourable outcome of
the illness. There is a imstaken belief in Britain that patients who talk
about committing suicide never do it. This is not true; the expression
of suicidal ideas must always be treated seriously and patients who talk
of suicide should be referred immediately to a psychiatrist for an accurate
assessment of their mental state.

238

CHAPTER XVI

THE ELECTRO-ENCEPHAl-OGRAPH IN PSYCHIATRY

No atteinpl will be made to give an exhaustive account of the value of
the clectrO'encephalograph in clinical medicine. Two good introduc-
tions to this subject have recently appeared which should be consulted
by the interested reader.*

GENERAL PRINCIPLES

The Machine. — The electro-encephalograph records potentials
produced by the br^n which can be picked up by electrodes placed
on the scalp. The electrodes arc usually connected with the machine
in such a manner that it records the potential differences behveen nro
electrodes. The machine in common use has eight channels which
can amplify eight sets of potential differences simultaneously. These
arc then recorded by eight pens which write on a moving sheet of paper.
The potentials picked up from the scalp are usually of the order of 10
to 200 millionths of a volt ((tV) and are usually amplified to such an
extent that on input of too pV produces a i-cm. vertical deviation of
the pen. This is kno^vn as the *standard gain ’.

The Rhythms. — Certain basic rhythms can be recognized in an
E.E.G. It is customary to group together certain frequencies and to
designate these groups by Greek Ictten. They are: —

1. Alpha Rhythm. — ^Thisi38-i3cycIcspcr8econdincIusive. Wuleall
other rhythms are not restricted to a given site, alpha rhythm is 8--i3
cycles per second activity, which is decreased by eye opening and con-
centration and which occurs over the occipito-parietal region of the skull.
If activity of the same frequency occurs elsewhere it can be referred to
as being of ‘alpha frequency’, but cannot be called ‘alpha rhythm’.

2. Beta Rhythm , — This is above 13 cycles per second.

3. Theta Rhythm . — This is 4-7 qrcles per second inclusive.

4. Delta Rhythm . — This is bdow 4 cycles per second.

Phase Reversal — The tracings record the potential differences
beU%ecn two scalp electrodes. Let us suppose that three electrodes,
A, B, and C, arc applied to the scalp and the distances between A and

* Hughes, R. H. (1961). An ttOrodutiim to CHmeal Electro-enetphatography.
Bristol 1 Wrislit.

IOloh, L. G., and Ossslton, J. W. (19IS1), Ciimeal EleetTO-enctphahiraphy.
London: Dutterworth.

ELECTRO-ENCEPHALOGRAPH IN PSyCHIATRY 239

B and B and C are equal, and a sudden increase in potential occurs at
B. This means that A and C trill be negative with respect to B. The
input from AB is fed into the machine so that the pen trill move
upwards if B is positive in respect to A. On the other hand, the input
from BC is connected to the machine in such a way that if B is negative
to C the recording pen will move upwards. It follotvs, therefore, that
if B is positive in respect to both A and C the recording pens of the
E.E.G. vtill move in the opposite direction. They will be completely
out of step, or, to put the matter technically, there will be phase reversal.

If an abnormal rhythm appears in an E.E.G. and phase reversal occurs
between two channels then there is a focus of electrical activity beneath
the common electrode shared by the two channels. This usually means
that there is some physical abnormality at this point, but an electrical
focus can be produced by a disease process some distance from the focus.

The Normal E.E.G. —

The Adult . — ^The alpha rhythm is usually prominent, but traces of
theta activity may be seen, and slight beta activity is often present,
particularly in the central areas.

The Child . — In the first year theE.E.G. of the normal child shows low-
voltage delta and theta activity. At the age of about i 8 months runs of
low-frequency alpha rhythm are seen. As the child grows older the alpha
rhythm becomes more and more prominent, but even in adolescence
some theta activity remains. The persistence of marked slow activity in
late adolescence or adult life can be regarded as a sign of immaturity.

The Abnormal E£.G. —

Abnormal Rhythms . — The record may be abnormal in that it contains
rhythms which are normally absent or minimal at the subject’s age.
Thus there may be an excess of theta, delta, or beta rhythm, which
may be diifuse or focal.

Abnormal Wave Forms . — In some epileptics waves with a rapid rise
and fall, k□a^vn as spikes, are seen. Sometimes there is a sharp wave
instead of a spike. The presence of a spike or sharp tvave focus in a
record taken between seizures is diagnt^Uc of epilepsy.

The other abnormal wave form seen in epilepsy is the spike and
wave. This consists of a high-voltage, smooth, dome-shaped wave
followed by a high-voltage spike, usually occurring at the rate of three
per second. Patients who suffer from petit mal usually show this
pattern, but so do some patients who only have grand mal.

THE EJE.G. IN PSYCHIATRIC ILLNESSES

The Neuroses. — It has been found that in groups of mixed neurotics
the inddence of abnormal EX.G3 is greater than that in the general
population. This is mainly due to so-called maturation defects in the
shape of excessive theta actiri^.

240 AN OUTLINE OF PSVCniATRY

The Affective Psycbose$. — Several workers have found an excess
of abnormal records in series of manic-depressives, but their diagnostic
criteria are open to question. Some patients with temporal lobe fod
do not suffer from fits, but may have an epileptic dysthymia. The
E.E.G. should therefore be carried out in all cases of atypical depression.

Schizophrenia. — ^Variations in alpha rhythm, low-voltage fast
sctivity, slow wave activity, and low-voltage spikes have been found
in schizophrenics. Most of this work has been carried out on un-
selected chronic mental hospital patients, and no attempt has been
made to correlate the clinical findings with the E.E.G, record. Some
catatonics, when stuporose. show generalized diffuse slow artivity,
which disappears when the stupor is relieved.

Dementia. — On the whole, E.E.G. changes in dementia are related
more to the rate of progress of the dementing process than to the
aetiology or degree of the dementia. In Akheimer’s disease there may
be little or no alpha and generalized theta, with runs of delta activi^,
which is often of high voltage. This type of E.E.G. may be seen in
other presenile dementias. High-voltage sharp tvaves or spikes and
slow w'aves are seen in the E.E.G.S of patients suffering from Jakob
Creutzfeldt disease.

Psychopathy,— In a series of 194 aggressive psychopaths who did
not suffer from epilepsy, Hill found excessive theta activity in 22 per
cent, alpha variants in 3-2 per cent, and fod of 3-$ cycles per second in
the posterior temporal regions in 14 per cent. In the alpha variants
the subharmonic frequencies of alpha rhythm are present. Among
criminals, motiveless murderers and aggressive psychopaths in prison
have a very high incidence of abnormal E.E.O.S.

THE E.E.G. IN CUNICAL PSYCHIATRY

^Vhilc the E.E.G. is very useful in neurology, it is of little value in
clinical psychiatry. If a patient is suspected of suffering from an
organic state an E.E.G. should be performed. Usually organic states
present with a non-specific syndrome, but occasionally a depressire,
manic, or schizophrenic clinical picture may be due to coarse brain
disease. Frequently such dinical pictures are slightly atypical, so that
an E.E.G. should be canied out in every atypical functional psychosis.

Some patients with temporal lobe foci do not suffer from fits, but
may present with psychiatric clinical pictures which show mixtures of
psychotic and neurotic symptoms. Thus, over a period of eighteen
months one such patient showed severe depressive symptoms followed
by paranoid delusions and au^tory hallucinations, which in turn were
followed by hysterical behaWour. Finally, an E.E.G. showed focal
activity in the left posterior temporal repon.

241

CHAPTER XVII

METHOD IN PSYCHIATRIC CASE-TAKING

A SHORT scheme for use in psychiatric case-taking is described below,
and it is convenient to record the information obtained under two
headings : —

1. History.

2. Psychological examination.

I. HISTORY

Under this heading the following particulars should be obtained:
(i) Name, age, civil status; (2) Source of information, i.e., patient,
name of relative, letters from doctor or from social agencies; (3) Com-
plrint, or reason for seeking medical advice; (4) Family history; (5)
Previous pereonal history; (6) History of present illness; (7) Treatment
80 far given.

Person giving the Information (if other than the patient}.—

Impretsion of Infomant't Reltabilily, r/e.— Relatives should be asked
to give a history of the patient’s illness as they have seen it. This should
be set down separately from the history given by the patient.

Main Complaint or Reason for Admission.— Give a brief state-
ment and put in inverted commas words said by the patient.

Family History.— Race, social group, and general efficiency of
family. Fanulial diseases, alcoholism, abnormal personalities, mental
disorder, epilepsy.

Father. — H^th, age, or age at time of death and cause of death;
kind of personality; occupation.

Mother. — Health, age, or at time of death and cause of death;
kind of personality.

Siblings. — Enumerated in chronological order of birth wth Christian
names, ages, marital condition, personality, occupation, health, or ill-
ness. Miscarriages and stlUlHrths should be included.

Home Atmosphere and Influence. — Any salient happenings among
parents and collaterals during patient's early years; relationship of
patient to parents, relatives, and others in the home.

Personal History. — Date of birth and place; mother’s health
during pregnancy; attitude of parents towards pregnancy; full-term or
premature ? Was delivery normal ? Breast- or bottle-fed ?

16

242 AN OUTLINE OF PSYCHIATJIV

Early Development. — Precocious or retarded? Time of teething,
talking, tvaJking, cleanliness as to excreta. Delicate or healthy baby ?

Neurotic Traitf (in childhood). — Inquire regarding chorea, convul-
sions, night terrors, ^Talking in sleep, tantrums, bcd-wetdng, thumb-
sucking, nail-biting, faddiness about food, stammering, mannensms,
fears, notable behaviour, or escapades.

Play. — Make-believe, organiz^ g^es, type of children preferred.

School. — Age of beginning and finishing, schools attended, any
special medical or psycholt^cal examinations, standard reached,
evidence of ability or backu’ardness, aggressive or submissive at school ?
Attitude to authority, homework, etc.

Occupaliont (in Full Detail).— Age of starting work, jobs held, in
chronological order, tvith wages, dates, reasons for change. Satisfaction
in work, present economic circumstances.

Menstrual History. — Age at first period, attitude of patient and
mother; regularity, duration, and amount, psychic changes, climacteric
symptoms.

Sexual Inclinations and Practices. — Sexual information, how ac-
quired ? Masturbation, guilt, sexual fantasies, homosexuality, betero-
sevuai experiences apart from marriage, marfcaf relafions.

Marital f/irtcry.— Duration of acquaintance before marriage and of
engagement, partner’s age, occupation, personality, compatibility,
sexuid satisfaction or frigidity ? Contraceptive measures, common
tnteresu, differences and arguments, in-Iatvs.

CAi/dren.— Chronological list of children, gi\ ing ages, names, person-
ality. Mention miscarriages.

Habits. — ^Alcohol, tobacco, drugs; specify amount taken recently
and earlier. Type of drinker — gregarious or solitary, continuous or
’spree’ ?

Medical Htslory. — Illnesses, operations, accidents, in chronological
order.

Previous Psychological Illness. — Obtain a detailed account; dates,
duration, symptoms 0/ attacks, in what hospital or out-patient depart-
ment ? Find out where records are likely to be obtainable.

Previous Personality, — In desenbing the personality prior to the
illness do not use technical terms, but give illustrative anecdotes, state-
ments, or other evidence. Aim at a detailed picture of the individual,
giving his own words when necessary. The following is a collection of
headings, indicating the kind of information to be sought

I. Social Relations: Adaptation. —

To family: Degree of independence from rebtives.

To friends: Societies, cluf». Was he inclined to lake the lead or to
follow ?

METHOD IN PSYCHIATRIC CASE-TAKING 243

To highly organized aetivitietx Religion, politics, art.

To icork and Korkmata: Success.

What are his hobbies ? How does he use his leisure ? Does he
indulge in romantic or imaginative fantasy or daydreaming? Has
be a great desire for attention ? Is be easily influenced ? Wilful ? Is he
timid ? What interest has he in dress and habits generally ? Is he
sociable or seclusive ? Is he reserved, shy, self-conscious, sensitive,
suspicious, resentful, quarrelsome, over-conscientious, strict, exces-
sively orderly, irritable, impulsive, jealous, eccentric, selfish ? Manner-
isms. Attitude in moral issues.

2. Intellectual Activities. — Observation, memory, judgement, alert-
ness, reading, types of books and papers preferred ? Special abilities.
Inquisitive ? Thoughtful, prone to ruminate ?

3. Mood. — Generally cheerful, despondent, pessimistic, anxious,
worrying, self-depreciative or satisfied ? Confident ? Fluctuating with
or without occasion ? Emotionally demonstrative ?

4. Energy. — Output sustained or fitful ? Rhythm, initiative. Reso-
lute or undecided ? Ambitious ?

5. Habits. — ^Eating, sleep. Attitude to health; interest in body
tegular or changeable ?

Present Illness, — Give an account, in chronological order, of the
development of the illness from the earliest time at which a change was
noticed until admission to hospitaL Give data permitting the sequence
of various symptoms to be dated approximately. (Write in the third
person.)

2. PSYCHOLOGICAL EXAMINATION

Under this heading the following particulars should be noted:
(1) General appearance and behaviour; (2) Talk (with verbatim sam-
ples, if these convey the best impression); (3) Mood; (4) Orientation
and attention; (5) Special preoccupations and interests; (6) Delusions,
hallucinations, and obsessions; (7) Memory; (S) Insight and judge-
ment.

General Behaviour, — Give a description as complete, as accurate,
and as life-like as possible of what you can observe in the patient’s
behaviour. Does the patient look ill ? Is he in touch with his sur-
roundings in general, and in particular ? What gestures, grimaces, or
other motor expressions, tics, or mannerisms are present ? Does he
display mudi or little activity? Is it constant, abrupt, or fitful, spon-
taneous, or how provoked ? Is the patient free or constrained ? Is he
slow, stereotyped, hesitant, or fidge^? Note tenseness, scratching,
mannerisms, degree of attention. Do movements and attitudes have
an evident purpose or meaning ? Do real or hallucinatory perceptions

244 an outline of FSYCltlATRY

seem to modify behaviour } Does the patient, if inactive, resist passive
movements, or maintain an attitude, or obey commands, or indicate
awareness at all? Note habits of eating, sleep, and cleanliness in
general and as to excreta. Ascertun his way of spending the day.^If
the patient docs not speak the description of his mental state must be
limited to a report of his behaviour.

Talk. — The form of the patient's utterances rather than their ojn-
tent is considered here. Does he say much or little ? Does he talk
spontaneously or only in answer; simr or fast, hesitantly or promptly,
to the point or wide of it, coherently, discursively, loosely, with inter-
ruptions, sudden silences, changes of topic, comments on happenings
and things at hand, appropriately, or using strange words or syntax,
rhymes, or puns ?

Sample of Talk. — A sample of conversation should be recorded
verbatirru It should be representative of the form of his talk, his
response to questioning, and his main preoccupations. Its length will
depend on its individual significance.

Alood.— The patient’s appearance may be described so far as it is
indicative of his mood. His answers to, ‘How do you feel in yourself
'What is your mood ?', 'How about your spirits ?', or some similar
inquiry, should be recorded. Many varieties of mood may be present;
not merely happiness or sadness, but such states as irritability, suspicion,
fear, unreality, worry, restlessness, bewilderment, and many more,
which are convenient to include under this heading. Observe the
constancy of the mood, the influence which changes it, and the
appropriateness of the patient’s apparent emotional state to what
he says.

Delusions and Mislnterpretatloit.— W'hat is the patient’s attitude
to the various people and things in hb environment ? Does he mis-
interpret what happens, give it special or false meaning, or is he doubt-
ful about it ? Does he think that anyone pays special attention to turn,
treats him in a special way, persecutes or influences him bodily or
mentally, in ordinary or scientific or preternatural ways ? Docs anyone
laugh at him, shun Hm, admire him, or try to kill, harm, or annoy him ?
Docs he depredate himself in any regard; his morals, possessions,
health ? Has he grandiose beliefs ?

The patient may wish to conceal these matters and may have to be
patiently pressed.

Hallucinations and Other Disorders of Perception.— These
may be auditory, ^sual, olfactory, gustatory, tactile, or visceral. 'The
source, vividness, reality, manner of reception, content, and all other
circumstances of the experiences arc important; the content, especially
if auditory or visual, must be reported in detail. WTien do these

METHOD IK PSYCHIATRIC CASE-TAKING 245

experiences occur ? At night, when falling asleep, when alone ? Are
there any peculiar bodily sensations, for example, a feeling of
deadness ?

Compulsive Phenomena. — Does the patient have any obsessional
thoughts, inclinations, or acts ? Are they felt to be from without, or
part of his own mind ? Does their insistence distress him ? Does he
recognize their inappropriatencss ? ^Vhat is their relation to his emo-
tional state ? Does he repeat actions such as w'ashing unnecessarily, to
reassure himself ? Note phobias and anxiety.

Orientation. — Record the patient’s answ'ers to questions about his
own name and identity, the place where he is, the time of day, and the
date. Is there anything unusual in the way in which time seems to
pass for him ? Disorientation is very often missed if these inquiries
are not made.

Memory. — ^This may be tested by comparing the patient’s account
of his life with that given by others, or by examining his account for
evidence of gaps or inconsistencies. There should be special inquiry
for recent events, such as those of his admission to hospital and happen-
ings in the ward since. Where there is selective impairment of mcmoty
for special incidents, periods, or for recent or remote happenings, this
should be recorded in detail and the patient’s attitude towards his forget-
fulness and the things forgotten should be specially investigated. Record
the patient's success or failure in grasping, retaining, and being able to
recall spontaneously or on demand three or five minutes later a number,
a name and address, or other data. Give the patient a short story to
read (see p. 246) and ask him to repeat it in his o%vn words. Record his
repetition of the story verbatim if possible and whether he sees the
point of it. Give him digits forwards and then backwards and record
how many he can repeat immediately after being told them. The
Inglis Paired-associate Test may also be used (see p. 246). In de-
scribing the state of the patient’s memory do not merely record the
conclusions reached but give the evidence first, in full, and describe
at appropriate length such facts of behaviour as seem to indicate
whether he was attending, trying his hardest, or being distracted by
other stimuli, etc.

Grasp of General Informatfon. — Tests for general information
and grasp, as well as for ability to calculate, should be varied according
to the patient's educational level and interests, but the answers to the
following should be sought in all cases: Name of the Queen and her
immediate predecessors; Names of the Prime Minister and Chancellor
of the Exchequer; the capitals of France, Germany, Italy, Spain,
Scotland; dates 0/ the beginning and end of the tw'o world wars; the
names of six large cities in Great Britain; subtractions of serial sevens
from too. (Note down the answers and time taken.)

AN OUTLINE OF PSYCHIATRY

246

These tests are not intended so much as a test of general intelligence
as to see whether there has been any falling away from the patient’s
former presumptive level of koonle^e and capacity.

Insigiit and Judgement. — What is the patient’s attitude to his
present state ? Does he regard it as an illness ; as ‘ mental ’ or ‘ nervous ‘ ?
Does be feel he is in need of treatment ? Is he aware of mistakes he
has made spontaneously or in performing tests ? What is his attitude
to bis previous experiences, mental illnesses, and to the intcrvie%v ?
What is his attitude towards social, financial, domestic, and ethical prob-
lems ? ^Vbat does he propose to do when he has left hospital ? Does
he appear to be able to make sound judgements about his oun future ?

Simple Memory Tests. —

1. ‘ The Donkey and tht Salt '. — ^The following story may be read by
the patient: —

'A donkey loaded with salt had to ford a stream. He stumbled and
fell into the wnter. It took him a few minutes to get to his feet, and
when he did so he found that the load was much lighter, because the
salt had dissolved in the water.

‘He had to cross the stream the nert day, when he was loaded with
sponges. He remembered what liad happened the day before, so he
deliberately stumbled and fell into the water. The sponges soaked up
so much water that be could not get to his feet again and he was
drowned.’ The moral is ; ‘The same remedy does not apply in all cases. ’

2. The Name and Address. — ^Thls should be read to the patient and
he should be asked to repeat it immediately. If he fails to do so it
must be repeated until he can reproduce it accurately. The number of
repetitions neceaaaiy should be recorded, as this may give some idea
of the degree of anxiet)-. Once the address has been learned the patient
should be asked to reproduce it after five minutes. The following name
and address can be used: 'Mr. Robert Johnson, 53, Becchmont Drive,
Manchester, 5’.

3. The Inglts Paired-assoaate Test. — The test itself is of the ordinary
paired-associate learning type, employing verbal presentation and the
simple recall form of repr^uction. T%to altcmaihe sets of stimulus-
response material (whose statistical equivalence has been demonstrated)
have been used, as follows: —

F0R.M A Form B

Stimulus Response Stimulus Response

(а) Cabbage Pen Flower Spark

(б) Knife Chimney Table River

(c) Sponge Trumpet Bottle Comb

The patient is given instructioQS much like those for the paired-
assodateitemof the WechsIcrMemorj’ Scale. He is told; ‘I am going

METHOD IN PSYCHIATRIC CASE-TAKING 247

to read you a list of words, two at a time. Listen carefully, because after
I finish I shall expect you to remember the words that go together. For
example, if the words were “East — ’West, Gold — Silver”, then when I
said tile word “East” I should expect you to answer “West” and when
I said the word “Gold” you would, of course, answer (pause) ...
“Silver”. Do you understand ? Now listen carefully to the list as I read
it’.

The examiner allows an interval of about 5 seconds between the pairs
of words when reading the list. After the presentation of the list
another 5-second interval is allowed. The stimulus words are then
presented one by one in random order. Thus, the examiner asks:
‘What went mth “Flower” ?’ The patient is then allowed about 10
seconds to reply and if his answer is mnect the examiner says, ‘That's
right’. If the reply is wrong he says, ‘No’, and supplies the correct
association. If no reply is given by the patient within about 10 seconds
the correct response is again supplied by the examiner.

The material is presented in this way until the patient gets three
consecutive correct responses for each stimulus tvord or until each
stimulus word has been presented thirty times, whichever is sooner. The
examiner stops presenting each stimulus as Its criterion is reached.
Supposing that one pair is learned to the criterion before the other two
then the appropriate stimulus word is dropped out and the remaining
pair are simply alternated.

The score on this test is the sum of the number of times the stimulus
words are presented before the criterion Is reached. Inglis compared
a group of elderly patients \rith obvious memory disorder with a control
group matched for age and intelligence. The mean of the group with
memory impairment was 59-0 %vith a standard deviation of 25*06, and the
mean of the control group was 13*0, with a standard deviation of 6*i6.

24S

FURTHER READING LIST

TiiB purpose of this lut is to give the postgraduate student some Idea of suitable
books and articles that are t^orth consulting. It is not an exhaustive list and is
best regarded as a series of signposts vshich will help the postgraduate student
to find his way. The intetcsted undergraduate student, and indeed the
intelligent layman, thould read all those books in this list which have been
published by Penguin Books Ltd.

General Works.— There are a large number of textbooks and general works
on psychiatry in English. The following are useful:—

Arieti, S. (ed.) (1939). Ameriean Handbook of Psychiatri', vols. I and II.
New York: Basic Books. This is a veiy uneven bo^ and reflects the current
neglect of clinical psjxhiatry in the United States.

CfUEROV, N. fi947), 77 /e Pij-ehotogy ej the Be}unii>r Diserdert. Boston;
Houghton and hlifflm. This book and the following one are an attempt to
present a behaviourist ic psychiatry. They both deal w ith signs and symptoms
in a way that is unusual in textbooks written in English.

— — (tgbj), Pertonality Development and PtyehopoiJtelogy. Boston: Houghton
and hlifRin. This is the best textbook of dynamic psychiatry and should be
read by all postgraduate students.

— *— and Maoaret, A. (t 9 s 0 > Behavior Pathology. Boston: Houghton and
MifUtn.

PlXMfNG, G. W. T. H. (ed.) (1950), Betent I^ogrett in Ptythiatry, vol. a.
London: Churchill.

— »— (ed.) (1958), Ibid., vol. 3. London: Churchill.

ruEtBMAN, A. hi., and Kaplan, H. I. (1967). Comprehentivt Textbook of
Psychiatry. Baltimore: Williains and Wtlkios. TTiis book is somewhat weak
on the cluiical aide, but contains excellent reviews of non>clinical topics such
as epidemiology, community psychiatry, and so on.

Henderson, D, K., and DATanxoR, I. R. C. (1962), A Textbook of Psychiatry,
9th ed. London: Oxford University Prew. This is a standard textbook
which contains some rather unorthodox views on paranoid states,

Jaspers, K. (196a), General Psychopaihoiogy (tnns. IIa.milton, M. W., and
Hoenic, J.). Manchester: Univeiaity Press. This is an excellent survey
of psychiatry which should be read by every postgraduate student of
psychiatry.

Lewis, A. (1967), InquMei in P^ehialry. London: Routledge and Kegan Paul.

(1967), The Stale of Psychiatry. London: Routledge and Kegan Paul.

The first volume contains the dassic articles on insight, melancholia, and
obsessional illness. The second volume deab with historical topics and
general problems of psychiatry. Both volumes should be read by post-
graduate students of psychiatry.

AtAYER-Gsoss, W., &JtTER, E, and Rurw, W. (f9do), CUrdail Psychiatry.
London : Cassell. This book is written tsosis an ‘oiganicist ’ viewpoint and pays
little attention to the psychological aspects of mental disorders. There b no
general discussion of symptoms. Tlie section on the orgamc aspects of
psychiatry is very detailed.

FURTHER READING LIST 249

Noyes, A. P., and Kolb, L. C. (1963), Modern Cltnical Psye/natry, 6th ed.
Philadelphia: Saunders. This is wrineti from a ‘dynamic’ point of view
and is a good corrective to the 'organkist' approach. It also has an excellent
bibliography of works written mainly in English.

Penfosb, L. S. (1963), The Biology of Mental Defect, 3rd ed. London:
Sidgwick and Jackson. This excellent work also includes a chapter on the
genetics of mental illness.

Schneider, K. (1959), Ctinieal P^hopathology (trans. Hamilton, M. W.).
New York: Grune and Stratton. This book contains a group of essays on
various psychiatric topics which should be read by all postgraduate students.

The History of Psychological Medicine. —

AcKERKNECHT, E. H. (i9S9), A Short History of Psychiatry (trans. Wolff, Z.).
New York: Hafner. This is an excellent short account of the history of the
specialty.

Altschule, M. D. {1957), Bools of Modem Psychiatry. New York: Grune
and Stratton.

Henderson, D. K. (1951}, Introduction to The Collected Papers of Adolf Meyer,
vol. 2. Baltimore: Johns Hopkins Press.

Jaspers, K. (1962), General Psychopathology (trans. Hasiilton, M, W., and
Hoenio, J.). Manchester: Umvereity Press.

The Schools of Psychiatry. —

Ansbacker, H. L., and Ansbacher, R. R. (1958), The Individual Psi'chology of
Aifred Adler. London: Allen and Unwin.

Brown, J. A. C. (1961), Freud and the Post-Freudians. Harmondsworth,
Middx.: Penguin Books Ltd.

Fsnickel, O. (1945), The Psychoanalytic Theory of the Neuroses. New York:
Norton.

FORDHASf, F. (1953), An Introduction to Jung’s Psychology. Harmondsworth,
Middx. : Penguin Books Ltd.

Fbeod, S. (1947), New Introductory Leetsnes on Psychoanalysis. London:
Hogarth.

— - — (1949), Introductory Lectures on Psychoanalytu. London: Allen and
Unwin.

(1954), The Interpretatson of Dreams. London: Allen and Unwin.

Guntrip, H. (1961), Personality Structure and Human Interaction. London:
Hogarth.

Jacobi, J. (1951), The Psychology of C. C.Jung (trans. Bash, K. W.), sth ed.
London: Routledge and Kegan Paul.

JONTS, £. (1954), Sigmund Freud. Life and Work, vols. 1-3. London: Hogarth.
Juno, C. G. (1953), Two Essays on Analytical I^yehology (trans. Hull, R. F. C.).
London: Routledge and Kegan Paul.

Munroe, R. L. (1957)1 Schools of Psychoanalytic Thought, London: Hutchinson.
Pavlov, I. P, (i960), Conditioned Reflexes (trans. Anrep, G. V.). New York:
Dover Publications. This is a re-issue of a aeries of lectures first published
ia EngUsU ux tqzh. They give a. clear account of Pavlov’s baaio ideas and.
should be read before any attempt is made to understand Pavlovian psychiatry.
— — (1962), Psychopathology and I^yckiairy. Selected Works. IVIoscow:
Foreign Languages Publishing House.

Sullivan, H. S. (1955), Conceptions of Modem Psychiatry. London: Tavistock.
Wat, L. (tgs(>)i Alfred Adler: an Introduction to hu Psychology. Harmondsworth,
Middx.: Penguin Books Ltd.

AN OttTLINE OP PSYCHIATRY

250

WelIS, II. K. (1956), Pavlov and Fretid: I. Ivan P. Pavlov. Touards a Scien-
tific Ptychoh^y and Psychialry. London: Lawrence and Wishart.

(i960}, Pavlov and Freud: IL Signiund Freud. A Pmlovian Critique.

London: L,avvrence and ^ishan.

Aetiology and General Principles. —

Bowtity, J. (1932), MaternalCareand Menial IlealjJi.World Health Organiza-
tion Monograph Series No. 2. znded. London: H.M.S.O.

CowiE, V., and Siateb, E. (i 958)> in Pecent Progress in Ptyehiatry (ed.

Floiing, G. W. T, H.), V0I.3, pp. 1-53. London: Churchill.

Hamerton, J. L. (cd } (1962), Chromosomes in Medicine. London: Heinemann.
Hare, E. II. (1956}, 'Family Setting and the U/bsn Djstnburion of Schizo-
phrenia', J. tnent. Sri., 102, 753.

Jackson, D. (ed.) (i960), Etiology of Schizophrenia. New York; Basic Books.
Jaspers, K. (1962), General PsyeftopatAology (trans. Hamilton, M. \V., and
HOENIO, J.). Manchester: University Press,

Krinclen, E. (1968), Heredity and Cntironmmt tn Ike Functional Psychoses.
London: Heinemann.

Slater, E. (1933), ' Paychoticand Neurotic Illnesses in Twins', in Special Report
of the Medical Research Counrt?, No. 278. London: H.M.S.O.

S\ryTlllE3, J. R., CoppEN, A., and KnrttMAN, N. (1968), Biological Psychialry.

A Revieta 0/ Recent Advances. London: Heinemann.

W'OOTON, D. (1959). Soa'al Science and Soetal Pathology. London: Allen and
Unwin.

World H£U.n{ OncANttAwn (1962), 'Deprivation of Maremsl Care', In
World Health Organization PuiUe Health Papers, No. 14. Geneva. W.II.O.

General Symptomatology.—

Ackner, 0. (1954), 'Oepetsonahsation. 1',^. ment. Set., too, 838.

*** — (1954). ‘Depersotuluation, II', Jtid., too, 854.

ArnoLP, M. D. (1961), Emotion and Personality, vol. i. London; Cassell.
Dletler, E. (1951), Textbook a/ Psychiatry (trana. Diuix, A. A.). New York;
Dover. The first 156 pages of this book ere probably the most exteuive
discussion of psychiatric symptoms in the English language. 1 1 » unfortunate
that the translation is poor.

Brain, W. R. (1961}, Speech DitorJert—Aphatia, Apraxia and Agnosis. London:
Buttemonh.

Fisit, F. J. (1962), Schizophrenia. Bristol: Wright.

Hoenic, j., Anderson, E. W., Kdjna, J. C., and Blunsen, 1L (1962), 'Clinical
and Psychological Aspects of the Mnesric Syndrome \y. ment. Set., SoS, 541.
Kasanin, j. S. (ed.) (1944), Language and Thought in Schizophrenia. Berkeley:
University of California Press.

Lesvis, a. j. (1934), 'Insight', Bnt.J. med. Psychol., 14, 332.

The Neuroses.—

Bli^, E. L., and Branch, C. H. (i960), Anorena Henosa. New York: Hoeber.
Brown, F. (1936), 'Hrp<>^ondrtasa\y. meru, Sei., 8z, 395.

Fbnichel, O. (i 94 s). The Psychoanalytie Theory of the Neurons. New York:
Norton.

Freud, S. (1924), Collected Papers, vofa. 1-5, London: Hogarth.

I.EWIS, A. J. (1936), 'Obsessional IHness*. Proe. roy. Soe. Med., 29, 13.

FURTHER READING LIST 251

Rado, S. (1959), ‘Obsessive Behamor*. in American Handbook of Psychiatry
(ed. Abieti, S.). New York: Basic Book*.

Schneider, K. (1959), ‘Abnormal Reactions to Experience’, in Clinical
i’ryeAo/>flt/io/o^y (trans. Hamilton, M. W.). New York: Gnine and Stratton.
Stencel, £. (i960), ‘Classification of Mental Disorders’, Bull. Wld Hlth
Org., 21, 601. (Also published separately.)

Psychopathic Personalities. —

Henderson, D. K., and Batchelor. 1 . R. C. (1962), ‘Psychopathic States’, in
A Textbook of Psychiatry, 9th ed. London: Oxford University Press.
Schneider, K. (1958), Psychopathic Personalities (trans. Hajiilton, M. W,).
London: Cassell.

WooTON, B. (i9S9), Social Science and Social Pathology. London: Allen and
Unwin.

Psychosomatic Disorders. —

Alexander, F. (1952), Psychosomatic Medicine. London: Allen and Unwin.
Dunbar, P. (1954), Emotion and Bodily Change. New York: Columbia
University Press.

Grinker, R. R., and Bobbin, F. P. (1954), Psychosomatic Casebook. New York:
Blakiston.

WiTTKOWBR, E. D., and Clechoan, R. A. (1954). Recent Developments in
Psychosomatic Mtdscxne, London: Pitman.

Alcoholism and Drug Addletloo.—

Hoch, P. H., and Zubin, J. (ed.) (1958), Problems of Addiction and Habituation,
New York: Grime and Stratton.

Kennedy, A., and Fish, F. J. (1958), ‘Alcoholism, Alcoholic Addiction and
Drug Addiction', m Recent Progress in Psychiatry (ed. Flemino, O. W. T. H.),
vol. 3. Ixmdon: Churchill.

Kruse, H. D. (ed.) (1956), Alcoholism as a Medical Problem. New York:
Hoeber-Haiper.

Mann, M. (1957), Primer on Alcoholism. London: Gollancz. Thu book can
be read with profit by everyone interested tn alcoholism, including alcoholics.
World Health Organization (1952), Technical Report Senes No. 48. Expert
Committee on Mental Health. Afcoholum Subcommittee Second Report.
Geneva; W.H.O.

Affective Disorders, including Manlc>depresslve Disease. —

Kraepelin, £. (1921), Manie~Depresstve Insamty and Paranoia (trans. Barclay,
M.). Edinburgh: Livingstone.

Lewis, A. J. (1934), ‘Melancholia. A Survey of Depressive States’,^, ment. Set.,
80. 277.

— — (1936), ‘The Prognosis in Manic-Depressive Psychosis’, Lancet, 2,997.
Schizophrenia and Paranoid States.—

Bellak, L. (1958), Schizophrenia A Retneto of the Syndrome. New York:
Logos.

Bleuler, E. (195s), Dementia Praeeos or the Group of Schizophrenias (trans.

ZiNKiN, J.). London: Allen and Umrin.

Fish, F. J. (1962), Schizophrenia. Bristol: Wright.

Jackson, D. (ed.) (i960), Etiology of Schizophrenia. New York: Basic Books.

AN OUTLINE or PSTCHXATRT

252

KRAEretiN, n. (1919), Dementia Prateox and Paraphrenia (tnns. Barclay, M.).
Edinburgh: Livingstone.

RichtiR, D. (ed.) (1957), iS<Ai»^Ar<niB. Samatie Atpeett. London: Pergamon.
Smythies, J. R. (1963), Bioehemiftry 0/ Sehsxephrenia^ Springfield, IlL;
Thomas.

Organic States.—

Dlzuler, M. {i9S»), ‘The PeTchialry of Cerebral Disease*, Bril. mtd.J., 2,
1233-

Mayer-Gross, W., Slater, C., and Roni, M, (i960), CUmeal Psychiatry,
pp. 303-543. London; CasaeR

Wolff, H. C., and Curran, D. (1935), ‘Nature of Delirium and Allied Stales’,
Arch. Neural. Psyehiai. (Chkaga), 33, 1*73.

Sexual Dlaordera, —

Allen, C. (1958}, Homosexuality. Us Nansre, Causation and Treatment.
London: Staples.

— — (1962), A Textbook of Psychottxual Disorders, London: Oxford
University Press.

West, D. J. (1953), Homosexuality. Harmoodanrorth, AltddaL.’ Penguin Boobs

Treatment and Management. —

AcENSt. B., flARRts, K., and Ou>ham, H. J. (1957), 'Insulin Treatment of
Sebizophreiua', Lancet, t, 607.

— — and Olskaai, H. J. (1962), 'Insulin Treatment of Schizophrenia. A
Three-year FoIIow-up of a Coatrolled Study’, lUd., i, 504.

C0L8Y, K. M. (1951), A Primer for Psyehotharopy. New York: Ronald Preu.

Dally, P, (1967), Chemotherapy 0/ Psyehialrie bisordert. London: Logos Press.
A clear, conase, welUbalan^ account of the use of drugs in psychiatry.

Falcoser, M., and Sckvrr, P. H. (1958), 'Surgical Treatment of Mental
Illness', in J7«erif Progress in Psyehiatry (ed. Fleming, G. W. T. H.), voL 3.
London: Churchill.

Greenblatt, M., LeviA'son, D. J., and Wiluams, R. H. (t9S7). The Patient
and the Mental Hospital. Glcnooe, 111.: Free Press.

and Si>«ON, B. (1959). Rehabililaiion 0} the Mentally 111 — Sonal and

Economic Aspects, Washington, D.C.: American Association for the Advance-
ment of Science.

Jacobsei, E. (1959), 'Comparative Pharmacology of Some Psychotropic
Drugs', Bull. WlJIIlih Org., 21, 411.

Kra-vor, B. M. (1962), Day Hospitals. New York: Cruae and Stratton.

Ross, T. A. (1949), The Common Neuroses— Their Treatment by Psychotherapy,
2nd ed. London: Arnold.

Salter, A. (1952). Conditioned Keflex Therapy. London: Allen and Unwin.

Sabcant, W., and Slater, E.(i956),PAyrieal Methods of Treatment in Psychiatry,
4th ed. Edinburgh: LivingsKMie.

Schultz, J. H., and Luthe, W. (i 959)> Autogense Training. A PiycAopAyno-
logieal Approach in Psychotherapy. NewYotk: Gnine and Stratton.

Si«3*HEBD, M., and W’ino, L. (1962), 'Riarmacological Aspects of Psychiatry’,
in Advances in Pharmacology (cd. GaratttNI, S., and Shaw, P. A.}, toL i.
New York: Academic Press.

Storrow, H. a. (1967), Inirodaetum to Scientific Psychiatry. New York:
Applcton-Century-Crofcs. Tha is a stimulating introduction to behanour

FURTHER READING LIST

253

Sullivan, H. S. (1954), The Ptychiatrie Intervieia. London: Tavistock.

WOLPE, J. (1958), Psychotherapy by Reeipneal Inhibition. Stanford: University
Press.

Forensic and Administrative Problems. —

Davidson, H. A. {1952), Forensic Psychiatry, New York: Ronald Press.

East, N. (1950), ‘Deliquency and Crime', in Recent Progress in Psychiatry
(ed. Fleming, G. \V. T. H.), vol. 2. London: Churchill.

Edwards, A. H. {i^(ti),Menl^ Health Services, London: Shaw,

Gibson, E., and Klein, S. (1961), Murder. A Home OfRce Research Unit
Report. Lxindon: H.M.S.O.

Gould, J. (1958), ‘The Psychiatry of Major Crime’, in Recent Progress in
Psychiatry (ed. Fleming, G. W.T. H.), vol, 3. London: Churchill.

Stengel, E., Cook, N. G., and Krcecer, I. S. (1958), Attempted Suicide. Its
Social Significance and Effects. London: Chapman and Hall.

Williams, G. (1958), The Sanctity of Life nnd the Criminal Late. London:
Faber.

*54

GLOSSARY

The purpose of this glossary is to help the newcomer to psj'chutiy
and those without a medical training. It is not intended to be a psychi-
atric diaionarj’. The entries of technica! phrases are to be found under
the first letter of the first word. For example, ‘Primary Gain’ is to be
found under the letter 'P' — not under the letter 'G',

Abnorslu, Personality: A personality trith traits which deviate
markedly from what is generally accepted as normal. TTiis devia-
tion is a quantitative and not a qualitative one.

Absence: A temporary loss of consdousness due to epilepsy without
any convulsive phenomenx
Active Algoucnia; A synonym for sadism (q.v.),

Aftect: a sudden accentuation of emotion, which is intense, does not
last long, and is often reactive.

Affective Disorder: Some ps)’chiatrisi$ regard all illnesses in which
there is a primary disorier of affect as syndromes which can be
isolated from a vast group of affective disorders.

Agnosia: A failure to recognise a pattern of sensation presented in a
given sensory chann^. This is due to coarse brain disease. It can
be classified according to the sensory channel affected, so that
there is visual agnosia, auditory agnosia, tactile agnosia, and so on.
Acorapiiobia: A morbid fear of open spaces.

Agraphia; A loss of ability to write in the absence of any disorder of
the part of the nervous system responsible for hand movemertts.
.Aim iNHlumoN: The child eliminates the erotic elements in his
attachment to a loved object, but retains the feelings of love and
tenderness towards the object. Some gratification of the original
cathexls (q.v.) still occurs.

Akinesia: A state in which the patient shows no voluntary movements.
Akitiiisia: An unpleasant feeling of restleasncss accompanied by over-
activity which is produced by some phenothiarines.

ALConoL Addiction: This is recognk^ by the inability to stop
dw^Dgonct tbeiadividuallm btyua lo drink alcohol.
Aucoiiolis^i: This term is often used to designate heavy drinkers or
alcohol addicts (q.v.). It is best restricted to those persons who
have permanent mental or physical defects due to prolonged
excessive consumption of alcdtol.

GLOSSARY

255

Alexia: A loss of ability to read or an inability to leam to read in the
absence of any disorder of the visual cortex and the oculomotor
apparatus.

Allelomorphs: A pdr of genes which determine the inheritance of a
particular character.

Alogia: Negative formal thought disorder. (See Formal Thought
Disorder.)

Amentia: Sometimes used in Britain as a synonym for mental defect.
In German-speaking countries it means a subacute delirious state.

Amnesia: A loss of memory.

Amnestic Syndrome (Amnestic State): A subacute organic psychi-
atric state in which the presenting features arc difficulty in the
registration of new memories, confabulation, and complete dis-
orientation for time and place. Comprehension is disordered and
there is ‘tram-line’ thinking. Also called the ‘Korsakoff State’ or
‘Korsakoff Syndrome’.

Anal Eroticism: The enjoyment of the sensations which occur during
defaecation and the voluntary retention of faeces. According to
Freudian theory this occurs in the ana] sadistic stage of libicUnal
development.

Analytical Psychology: The psychological theories of C. G. Jung.

Anankastic Personality (Anankast): The overmeticulous, rigid,
precise individual often referred to in Great Britain as an obsessional
personality and in the United States as a compulsive personality.
Personalities of this kind may or may not have obsessions and
compulsions.

Anorexia: Loss of appetite.

Anorexia Nervosa: A complete loss of appetite in adolescent or young
adult females, associated mth over-activity, the cessation of mens-
truation, and fine do^my hair over the back.

Anterograde Amnesia: Loss of memory for a period of time, during
which the subject is apparently conscious.

Anticathexis; According to Freud some unconscious ideas are likely
to produce emotional conflict if they appear in consciousness.
Opposing ideas are, therefore, given a charge of instinctual energy
in order to keep the troublesome ideas out of consciousness. This
process, which forms the basis of repression (q.v.), is anticathexis.
(See also Cathexis.)

Anxiety: An unpleasant affective state with the expectation but not
the certainty of something unpleasant happening.

Anxiety Elation Psychosis: A c]^oid psychosis (q.v.) in which there
is either a clinical picture of severe anxiety with ideas of reference
or ecstasy with a desire to help others.

256 AN OUTLINE OF PSYCHIATRY

Anxiety Hystpha: 'Hiis term was first used by Freud for a variety of
hysteria (q.v.), in which the anxiety was localized to one situation
and appeared as a phobia (q.v.), ft has also been used by some
psychiatrists to describe states in which, unlike classical conversion
hysteria, there is a mixture of anxiety and conversion symptoms,
and also to denote amue^ states in which the symptoms are used
unconsciously for gain.

Anxiety State: A psychogenic reacrion in which a normal person is
reacting to severe stress or an abnormal person is reacting to mild
stress. Marked anxiety may be a presenting symptom in depres-
sion (autonomous dysthymla), in schizophrenia, or in an organic
state.

Aphasia: A central disorder of speech in which the necessary pathways
to and from the brain are not disordered. (See Dyephasia.)

Aphonia: Loss of ability to phonatc, so that the subject can only
whisper. It is not uncommon in hysteria.

Apophanoxjs Idea: A delusional idea which suddenly appears in con-
sciousness with no previous preparation. It is also known as an
autochthonous or sudden delusional idea.

Apophanous Mood: A strange uncanny mood state in which the
pau'ent feels that there is something happening around him, but
he does not know what it is. A delusion^ mood.

Apophanous PERcn»TiON: A new significance is attributed to a per-
ception, usually in the sense of self-reference, in the absence of
any emotional or rational cause.

ApophaNY: a state in which one or more psychological phenomena
acquire a nerr delusional significance, i.e., primary delusional
e:^riences or experiences of significance are occurring.

AnaiinTPE: A Jungian term for the psychological expression of an
instinct which is to be found in the collective unconscious (q.v.).
Also used for collective images which are frequently found in the
unconscious.

AsYNDmc Thinking: Cameron’s term for positive formal thought
disorder, (See Forjial TnooGHT Disorder.)

Athlctic Physique: One of Kretschmer’s three types of physique, in
which there is a marked development of the skeleton and the
musculature.

Aura: A sensaUon or other psychological phenomenon, which occurs
immediately before the onset of an epileptic fit.

Autism: A turning away from reality and an excessive indulgence in
fentasy thinking.

AuTisnc TinxKiNG: Excessive fantasy thinking. Also known as
dereistic thinking.

GLOSSARY

AuToamioNOus Delusion; See Apopiianous Idea.

Aoto-eroticism: Masturbation (q.v.)-

Autonomous Dystiiymia: A depressive illness in which the mood is
qualitatively changed and in which early morning wakening,
diurnal mood variation, and over-valued or delusional ideas
associated tvith the patient’s basic worries usually occur. The ill-
ness may or may not be provoked by some external event, but
once it begins its course it is relatively independent of the causal
event and the environment.

Belle Indifference: Bland indifference in the presence of a hysterical
conversion symptom.

Bell’s Mania; Acute delirious mania; probably a severe attack of
mania with delirium due to exhaustion, malnutrition, drugs, or
intercurrent infection.

Bender: Alcoholic jargon for a period of continuous drinking which
lasts for a few days and stops because of lack of money or physical
exhaustion.

Bestiality: Sexual relations with an animal. Also known as ‘erotic
zoophilia*.

Binovular TtviNS: Twins who have developed from different ferti-
lized ova and therefore have different genetic constitutions.

Bisexuality: In psychoanalytic writings this expresses the fact that all
human beings have conscious or unconscious feelings for indivi-
duals of both sexes. Strictly it means the ability to have sexual
experiences with both sexes.

Blackout: In Britain this word usually means a loss of conscious-
ness or a loss of memory. As a technical term it designates a
loss of memory occurring after a few drinks of hard liquor, not
Sufficient to produce drunkenness. This marks the onset of
the prodromal stage of alcohol addiction and is also known as a
‘palimpsest*.

Body Image: This is the organization of all the sensory input from
the body to form an image or ‘schema’, which acts as a system of
reference for all bodily activities.

Bradypiirenia: A slowing down of mental processes, particularly
applied to the slow mental activity in post-encephalitics.

Broadmoor: A well-known English criminal lunatic asylum. The
term ‘Broadmoor patient’ is used in England as a substitute for
the older term ‘criminal lunatic’.

Broca’s Area: An area at the posterior end of the third left frontal
convolution of the brain. Broca claimed that it was responsible
for articulation, but it is now believwl to be the area of the brain
which is responsible for the final organization of the motor aspects
of speech.

258 AN OUTLINE OF FSYCHlAlK):

Bromism: Poisoning mth bromides, usually due to the administration
of medicines containing bromide. A blood*Ievel of aoo mg. per
too ml. is associated nith bromum in normal subjects, but in
elderly patients bromism may occur at blood bromide levels
between 100 and 200 mg. per too ml. It is unusual for blood'levels
below 100 mg. per too ml. to be associated with symptoms.

Castration Complex: An uncoosdous group of ideas associated with
anxiety and consisting of the fantasy that the penis or clitoris will
be removed by the parent of the same sex. This complex arises
at the Oedipal stage of libidinal development, when the child has
sexual desires for the parent of the opposite sex.

Catalepsy: A sjTionym for flexibilitas cerca (q.v.).

Cataplexy: A sudden loss of all power of movement and loss of all
muscle tone mthout loss of consciousness. This is often associ-
ated with narcolepsy (q.v.).

Catato.via: A variety of schizophrenia in which the outstanding symp-
toms are disorders of motor behaviour.

Catharsis: Literally ‘purgation*. Used In psychiatry for the relief
obtained by the intense expression of the emotion associated with
an unpleasant experience or a conflict.

Cathexis.’ Freud suggested that every idea was charged with instinc-
tual energy, which supplied the impetus for the e-tpresslon of the
idea. This attachment of a charge of Instinctual energy to an idea
is a cathexis.

Chromosome: These are microscopical structures into which the
nucleus divides at the beginning of cell division. Later, each
chromosome divides into two cquid portions. Chromosomes occur
in homologous pairs and carry genes (q.v,). Each species has
its specific number of chromosomes and in humans this is 46.
Since the individual develops from the fusion of two sex cells
it is necessary for the number of chromosomes to be halved
at some stage in the development of the sex cells. This occurs in a
special kind of cell division called ‘reduction division* or'meiceis*.

Clang Associations: Two thoughts are associated on the basis of
rhyme or assonance.

Coitus Intebhuptus; The removal of the penis from the vagina during
sexual intercourse, so that the ^eolation occurs outside the
vapna, A common but unsafe method of birth control. Freud
believed that this gave rise to anxiety.

Coitus Reservatcs: Cessation of sexual intercourse before either party
has had an o^asm.

Collective Unconscious; The part of the unconsdous which Jung
considered was not personal to the individual but was a part of
the inheritance of the human race.

GLOSSARY 259

Coiu: A state of unconsciousness due to acute coarse brain disease
from which the patient cannot be roused.

Complex: A group of repressed ideas and the affects associated with
them.

Compulsion: An act which the patient feek compelled to carry out,
although he realizes it is senseless and that he is not being directed
by outside influences. (See also Obsession.)

Concrete Attitude: Goldstein claimed that this attitude occurred in
coarse brain disease and In schizophrenia. The patient is unable
to think abstractly and to get away from the concrete aspects of the
situation.

Condensation: The fusion of heterogenous elements of thoughts,
based on non-logical assodations. A feature of the primary process
(q.v.), which is seen clearly in dreams and in schizophrenic
thinHng.

Conditional Reflex: Also incorrectly called a ‘conditioned reflex’.
A neutral stimulus is regularly applied to an animal just before
and during the application of a stimulus which is known to pro-
duce an unearned response. After some time the neutral stimulus
is capable of eliciting the response. A conditional reflex has been
formed and the previously neutral stimulus has now become a
conditional stimulus.

CoNFASULATio.v: Detailed plastic false memories. These are classically
seen in the amnestic state, but also occur in some chronic schizo-
phrenics and appredadon-needing psychopaths.

Confusion: This term is often used somewhat loosely for perplexity
or bewilderment. Strictly it should be reserved for those paUents
who show clear evidence of disorientadon for time and place.

CoNFOSlONAL State: A low-grade delirium, usually worse at night and
assodated with some degree of incoherence. The term ‘subacute
delirious state’ suggested by Mayer-Gross, Slater, and Roth is
more appropriate.

Confusion Psychosis; A cycloid psychosis (q.v.), in which there is
either a state of exdted incoherence or a poverty of speech with
perplexity.

Constitution: The total psychological make-up of the individual due
to the interaction, up to the time of consideration, of the inherited
predispositions, chance physical damage to the brain, and environ-
mental influences.

Conversion Hysteria; The partial solution of a psychological conflict
by the conversion of the conflict into a physical or mental symptom.

Coprophagia: Eating faeces. Occurs in young children, idiots,
dements, and some deteriorated schizophrenics.

26o AN' OVTLtNB OF PSYCHIATRY

CcNSlLlNCUS: The application of the mouth and the tongue to the
vul\*a, clitoris, or anterior v^na.

Ct'R.\TOR Bonis: A receiver appointed by a Scottish court to administer
the dnanctal affairs of someone trho is mentally unfit to do $o.

Cvetoro Psychoses; A group of recurrent mental disorders in which,
although the sjTnptomatology ts reminiscent of schizoplircnia,
complete recover)' occurs,

Cyclotiiymu: Used variously to mean manic-depressive insanity
and the mood variation of the cj'clothymic personality (q.v.).

Cyclothy'MIC PEttsoNAitTr: One of the four l>T5es of personality
associated trith manic-depressive insanity. The mood is elected
for several daj-s or weeks and then is depressed for a similar period,
after which a period of ebtion occurs, and so on,

DELlRltTki: An acute organic psychiatric state in which consciousness
is changed in a dream-like way.

Delusion: A false unshakeahte belief which is out of keeping tvilh the
patient's educational, cultural, and social background,

DE^tE^'TlA: A permanent loss of intellectual function due to coarse
brain disease.

Dementia Paaecox; A misleading, out-of-date B}uonym for tchuo-
phrenia (q.v.).

DETERSosALiiATiON: The subjective experience of the leas of empathy
(q.v.) and feelings for others.

Dereauzation: The subjective experience of unreality of the environ-
ment, although the subject knows that it is real. This usually
occurs in association with depersonalization.

Derf/STic Thinting: Synonjvn for autistic thinking (q.v.).

Dipsom-snia: Recurrent bouts of excessive drinking. These patients
are not alcohol addicts, but episodic psychopaths who from lime
to time arc unable to tolerate the tedium of everyday life.

Displacement: The use of an associated word or concept in place of
the correct word or concept. Thb occurs in the primary process
(q.v.) and can be seen in neurotic symptom formation, dreams,
and schizophrenic thinking.

Dissociation: A mental mechanism which splits off from conscious-
ness some mental contents which are troubling the conscious
mind.

Domina,vt Inheritance: The inherited character appears in the
phenotype (q.v.) when only one member of the allelomorphic
gene pair which carry the cha/Mter is present.

Drug Addictio.v ; A pyehological or phj’sieaj dependence on the effeeis
of a drug, which leads to an overpowering need for the drug and
to obtaining it by any means.

GLOSSARY 261

Dysmnesic Syndrome: A suggested synonym for amnestic syndrome
(q.v.).

Dysphasia: Since aphasia (q.v.) literally means an absence of speech
rather than a ^sorder of speech, some purists used the term
‘dysphasia’ instead.

Dysplastic Physique: A physique which shows some features of all
the three basic Kretschmerian ^es.

Dtsthymu: An unpleasant mood state. {See also Autonomous
Dysthymia.)

Echolalia: The patient automatically repeats the words spoken by
the examiner.

Echopraxia: The patient automatically repeats the actions carried out
by the examiner.

Ecstasy: A state of exaltation which can be seen in epilepsy, in schizo-
phrenia, and in abnormal personalities.

Ego: Freud used this term for that part of the mind whose contents
are potentially conscious and which balances the demands made
by Ae real world, the superego (q.v.), and the id (q.v.).

Ego Ideal: The conscious standa^ which the individual sets himself
to achieve.

Ego Psychology: Freud paid little attention to the ego and considered
that it derived its psychic energy from the id and superego. Some
of his pupils, notably Anna Freud, Hartmann, and Fedem, have
developed the psychoanalytic theory of the ego, which is usually
called ‘ego psychology'.

Ejaculatio Praecox; Ejaculation prior to or immediately after the
Insertion of the penis into the vagina.

Electroconvulsive Treatment (E.C.T.): An epileptic fit is produced
by the pass^e of an electric current through the head by means
of electrodes applied to the temples. Useful in the treatment of
depression (autonomous dysthymia) and depressive and catatonic
symptoms in schizophrenia.

Electroplexy: Synonym for electroconvulsive treatment.

Emotion: ‘The felt tendency toward anything intuitively appraised as
good (beneficial), or away from anything intuitively appraised as
bad (harmful). This attraction or aversion is accompanied by a
pattern of physiological changes organized towards approach or
withdrawal’ (Arnold).

Emotional Incontinence: Synoi^m for lability of affect (q.v.).

Empathy: The ability to feel oneself into the situation of another
person.

Endogenous Depression: A depresrive illness believed to be due to a
constitutional predisposition. Some psychiatrists believe that such

263

AN OUTLINE OF PSYCHIATRY

illnesses cannot be provoked external events and that deprcs.
sions pioduccd in this way are ‘reactive’ or 'neurotic'. The view
taken in this book is that endogenous depression can be provoked
by psychological traunu, but its subsequent course is independent
of the provoking factors. If this is the case the illness, ^though
constitutionally determined, cannot be called ‘endogenous*. (See
also Autonomous Dystiiyaha.)

Erotogenic Zones: Areas of the ^dy, usually mucocutaneous junc-
tions, which, when stimulated, give rise to erotic feelings. Accord-
ing to psychoanalytic theory the different stages of libidinal
development are related to the primacy of a particular erotogenic
zone.

Essential IlYrEirrENSioN: A condition in which the blood-pressure is
permanently raised for no known reason. This is supposed to be
a psychosomatic disorder (q.v.).

Euphoria: A mild persistent elevation of mood, usually associated
with a sense of bodily well-being known as 'eutonia'.

E.THinrnONlSM! Loosely used by tl>e laity to mean ‘showing off’.
Techiucally It is used for the sexual perversion in which sexual
pleasure is obtained from exposing the genitals to another
person.

ExJSTENTiALisvt: A philosophical trend which tries to place the Indivi-
dual in the middle of the world and to derive the meaning of his
existence from (he individual himself.

ExPEiu&rE.NTAL NEUROSIS: Non-adaptive behaviour produced in
animals by presenting them with an insoluble problem or some
other frustrating situation. Also called ‘animal neurosis'. Similar
conditions can be produced experimentally in humans. The
relationship of these states to naturally occurring human neurosis
is not clear.

Extraveesion: Jung divided personalities into two groups; those who
turned their psychic energy outwards and mode relationships
with others very easily, and (hose wrho turned their psj'chic energy
inwards and lived more in their Inner fantasies. The first type
were called ‘extraverts’, because they turn their psychic energy
outwards, while the second group were called 'introverts’ (q.v.).

- Fellatio: Licking or sucking the penis.

Fetishism: Obtaining sexual pleasure from an inanimate object.

Fixation: Freud described three main stages of infantile sexual
development at which conflicts could occur. If a conflict at one
of these stages is not fully resolved then fixation is said to have
occurred. This is because some of the libido or instinctual energy
is fixed at this point which U called the 'fixation point*.

GLOSSARY 263

Flexibiutas Cerea: A w'axy flesibiliQr, in which the patient allows the
examiner to put his body in any position and maintains the new
position for Airty seconds or more.

Flight of Ideas: A rapid progress of thought in which the individual
elements are not rationally connected, but where their sequence
depends on chance association, particularly on rhyming and asson-
ance (see Clang Associations). This disorder characteristically
occurs in mania but it is occasionally seen in schizophrenia and in
organic states.

Folie X deux: Induced insanity, in which one member of a household,
who is aggressive and assertive, develops a paranoid illness which
is imposed on a more submissive partner. When the two partners
are separated the induced insanity disappears.

Forepleasure: The enjoyment of sexual play before the insertion of
the penis.

Formal Thought Disorder: A disorder of conceptual thinking in
someone who has previously been able to think conceptually.
It may be negative, when the patient is unable to form con-
cepts; or it may be poative, when the patient produces false
concepts by means of condensation, displacement, or the misuse
of symbols.

Frigidity: The failure of a woman to achieve an orgasm during
sexual intercourse.

Fugue: A wandering state which may occur in hysteria or depression
(autonomous dysthymia).

Functional: This adjective is used by English-speaking physicians to
mean that they can find no physical disease and that the illness is
therefore psychogenic.

Functional Psychosis: This term is used to designate manic-depres-
sive disease and schizophrenia, since they are both serious mental
illnesses in which no physical changes in the brain have so far
been found. It is a convenient term, but it must be remembered
that the words ‘functional’ and ‘psychosis’ cannot be properly
defined.

Ganser State (Ganserism): Simulated madness, in which the patient
behaves in such a way as a lay person would expect a madman to
behave. He gives approximate answers which show that he knows
the correct answer. Despite an apparent absence of all knowledge
these patients can wash, dress, and take care of themselves. Also
kno^vn as ‘hysterical pseudodementia’.

Gene: A hereditary factor present in every cell. Any one inherited
character is determined by two genes which form a pair known as
allelomorphs.

264 AN OUTLINE OF PSYCHIATRY

Gener.\l Paralysis of the Insane (G.P.I.; General Paresis); A
dementia associated mth a spastic paralpis of all limbs due to
syphilis.

Genotype: The genetic constitution of the individual, as opposed to
the phenotype (q.v.), wWch is the physical expression of the genetic
structure.

Gerstmann’s Syndrome: Inability to calculate, agraphia, finger
agnosia, and right-left disorientation due to a lesion of the left
angular gyrus in the right-handed.

Globus Hystericus: The complaint of a lump in the throat and
difficulty in stvallowing found in some hysterical patients.

Grandiosity: The patient believes that he is much more important
than he really is. This may occur in mania, in schizophrenia, and
in general paresis.

Guardianship: Most European countries have legal provisions which
allow a mentally ill, psychopathic, or mentally defective person to
be deprived of bis dvi! rights to some degree. The patient is placed
in the care of a guardian in order to prevent him from wasting his
resources, being eTploited by others, or exposing bis dependants
to unnecessary hardship.

Hallucination; A perception without an external object

Hallucinosis: A state in which hallucinations are continuously
present.

Hebephrenia: A variety of schizophrenia in which the outstanding
feature is the disorder of affective expression.

Hemi-anaesthesia: A loss of sensation over one half of the body.

Hemiparesis: A weakness on one side of the body.

Hemiplegia: A loss of power in one half of the body.

Heterosesuality; Sexual desires and practices brtween members of
the opposite sexes.

Heterozygote: An individual who has an allelomorphic pair of genes
which are dissimilar.

Homosexuality; Sexual desires and practices bettveen members of
the same sex.

Homozygote: An individual who has a pair of allelomorphic genes for
a given character which are similar.

Hyperkinesia; A state of continuous over-activity of the voluntary
muscles.

Hypertension: Raised blood-pressure.

Hypnagogic Hallucinations: Halludnatlons occurring as the subject
is falling asleep. Th^ may occur in any sense modality but are
usually visual or auditory.

Hypnopompic Hallucinations: Halludnations occurring as the
sleeper is waking up.

GLOSSARY

265

Hypochondriacal Delusions: Delusions of bodily ill-health.

Hypochondriasis: A state of mind in vihich the patient believes or is
afrdd that he has a bodily illness, although there is no evidence
to support such ideas.

Hypomania: Mild mania, in -which there are euphoria, over-activity,
and prolixity without any flight of ideas. The patient is usually
able to put on a good front for a short period and to rationalize
his previous unruly behaviour.

HYPoniERiiiA: A body temperature below the normal range.

Hysteria: A mental illness in which the symptoms are unconsciously
moti^Tited.

Hysterical Personality: An individual who needs to be appreciated
and does not get the necessary appreciation without behaving in
an unusual way. As these patients do not necessarily suffer from
hysterical illnesses a better term is ‘appreciation-needing person-
ality*.

Hysterical Pseudodementia: A synonym for Ganser State (q.v.).

Iatrogenic Illness: A condition inadvertently caused by the opinion or
attitude of a doctor.

IcTAL: Appertaining to an epileptic ht.

Ictus: An epileptic 6t. This term is not often used in Britain.

Id: The unorganized, instinctual, unconscious part of the mind postu-
lated by Freud.

Identification: This term is used in two ways by psychoanalysts. It
can be used for the mental mechanism which operates when the
individual takes on the attitudes and ideas of another person, or
for the way In vshich the ego identifies one object with another.

Idiots: Prior to the recent Mental Health Acts the legal meaning of
this term was: ‘Persons so deeply defective in mind from birth,
or from an early age, as to be unable to guard themselves against
common ph}’sical dangers’.

Illusion: A false perception based on an incorrect interpretation of an
external stimulus.

I&lAGO: An unconscious organized image.

Imbeciles: The legal definition in Britain before the recent Mental
Health Acts %vas: ‘Persons in whose case there exists from birth,
or from an early age, mental defectiveness not amounting to
idiocy, yet so pronounced that they are incapable of managing
themselves or their affrirs, or in the case of children, of being
taught to do so*.

-* Incest: Sexual relations between dose blood relatives. According to
psychoanalytic theory unconsdous incest wishes occur in everyone.

Incoherent Thinking: Thought in -which no understandable con-
nexion between successive thoughts can be found.

266 AN OUTLINE OP PSYCHIATRY

Individual Psychology; The psydiological theories of Aifred Adler.

Induced Insakht: Synonym for folie h deux (q.v.).

Int»o;ection; The mental roechanism by which an object is incor-
porated into the nund; rather like the way in which food is
incorporated into the body.

Introversion: In psychoanalytic theory this is the turning back of the
libidinal energy on to the ego, bec^e an object has been lost and
the libido attached to it has Iwen set free. This is the initial stage
in a neurosis. In Jungian theory introveraion is the attitude of
turning in on oneself and living in one’s otvn fantasies.

Introvert: A person t^hose reactions and attitudes are mainly deter-
mined* by his inner life.

Inversion: A synonym for homosexuality.

Invert; A homosexual; but sometimes used hr a male homosexual uho
has very feminine ways.

Involution; Retrogressive physical and psychological changes occur-
ring in middle life. In women it occurs between 40 and 55 years
of age and in men between 45 and 60 years of age.

Involutional Melancholia: A severe depressive illness occurring in
the involution; characterixed by marked agitation, severe hypo-
chondriasis (especially alTecting the bowels), and by delusions of
guilt and persecution. Sometimes this term is used very loosely
for agitated depressions in middle life.

Isoution: a mental mechanism, particularly teen In obsessional
states, in which complexes iose their emotional charge and their
ideational associations, so that the idea may appear in conscious-
ness svithout the emotion, and vice versa.

Jacksonian Epilepsy; The fit begins in one part of the body, usually
the thumb or big toe, and spreads through the limb until the
whole body is affected and consciousness is lost This is due to a
focal lesion of the part of the brain immediately responsible for
motor activity. Also known as 'focal epilepsy’.

Jakob-Creutzfeldt Disease: A prcsenile dementia in which lesions
occur in the cerebral cortex, the basal ganglia, and the motor cells
of the spinal cord.

Korsaeoft’s PsYcnosis; An amnestic ayndrome (q.v.) or 'Korsakoff
state’, together with polyneuritis, usually due to prolonged abuse
of alcohol. Korsakoff was a famous Russian psychiatrist who, of
course, wrote his name in Cyrillic script. Unfortunately when he
wrote in German he transliterated hh name in at least two different
ways. The spellings * Korsakov* and 'Korsakow' are to be found
in the literature. The spelling given here was used by Korsakoff
himself on at least one occasion.

GLOSSARY

S ^

Lability of Affect: The patient suddenly bursts into tears or explodes*
into laughter as the result of a very slight emotional stimulus, or
even in the absence of any obvious emotional stimulus. Sudden
weeping is much more conunon than sudden laughter. This
symptom occurs in psychiatric organic states, particularly in
arteriosclerotic dementia.

Latency Period: According to Freudian theory infantile sexual de*
velopment ceases at about 4 to 5 years of age and is followed by
the latency period in which there is little interest in sex. This
lasts until the onset of puberty.

Leptosome: The leptosomic or asthemc body-build is the thin bony
habitus with poorly developed musculature. Usually the nose is
large and the chin recedes, pving rise to the so-called ‘angle
profile'. Kretschmer, who described this Ejody-build, claimed
that it was often found in schixophrenica.

Leucotomy: More correctly, ‘prefrontal leucotomy’. A neurosurgical
operation in which the fibres connecting the frontal lobes and the
thalanu are cut.

Ltswo: Generally used to mean sexual desire and drive. In the
Freudian sense it means sexual instinct and the psychic energy
associated vdth it.

Lilliputian Hallucinations: Visual hallucinations in which small
human beings or animals are seen.

XjOBOTomy: An American synonirm for leucotomy.

Logoclonu: The repeated utterance of parts of a word. This occurs
in coarse brain ^sease, particularly in Alzheimer’s disease.

Macropsia: An illusion in which objects appear larger than normal.

Mania: A mental illness characterized by elevated mood, Bight of
ideas, and over-activity.

Mania a pow: Pathological intoxication (q.v.).

Mannerism: A strange stilted execuUon of a voluntary action or a
distortion of a normal posture.

Masochism: Sexual satisfaction obtained from the experience of pain
and discomfort.

Masturbation: The subject produces sexual satisfaction by stimu-
lating his own genitals or other areas, e.g., the anus, likely to
cause sexual pleasure. Also inaccurately called ‘onanism’ (q.v.).

Megalomania: A psychosis wth delusions of grandeur. A term not
much used by English-speaking psjxhiatrists today.

Mental Defect: The English Mentid Deficiency Act of 1927 defined
this as: ‘A condition of arrested or incomplete development of
the mind existing before the ^e of eighteen years, whether arising
from inherent causes or induced by disease or injury’. In practice

268 AN OUTHKE OF PSYCHIATRY

mental deficiency has been used not only for patients with sub-
normal intelligence from childhood, but also for unstable, dull,
and backtrard children uho scored badly on intelligence tests.
The new English Mental Health Act uses the terms ‘severe sub-
normality’, ‘subnormality’, and ‘psychopathic disorder’ instead
of ‘mental deficiency*. The relevant Scottish Act docs not attempt
to define it.

Mental Disorder: The Mental Health Act, 1959, defines this as:
'Mental illness, arrested or incomplete development of the mind,
psychopathic disorder, and any other disorder or disability of
mind*.

Mental Health Officer: An official of a Scottish Local Authority
vrho has certain duties laid doxro by the Mental Health (Scotland)
Act.

Mental Welfare Officer : The English equivalent of a Mental Health
Officer.

Metapsychqlogy: Freud used this tenn for what is now usually
called 'depth psychology’, in order to express his concept that
mental functioning depends on faaors outside consciousness. It
is now used for the psj'choanalytlc theory which takes into account
the dynamics, structure, and economics of the mind.

Micropsia: An illusion in which objects appear smaller than usual.

Moral Imbecile: A person \rith no moral scruples, with or without
some degree of mental defect.

Moral Intantty: This term was first introduced by Prichard to
designate that %'aricty of insanity in which there were no delusions.
The word ‘moral’ in the early ninetcenih century meant much
the same as the word ‘psychological’ today. By the middle of the
nineteenth century the term ‘moral insanity* was used to describe
persons who would now be called 'psychopaths’ and 'alcohol
addicts’.

Mutism: Absence of speech from any cause.

Narcissism: Primary narcissism is the first stage of ego organization,
in which the child does not difierentiate between itself and the
emironment, so that the world is the child’s ego. In secondary
narcissism the structure 0/ the mind has fully developed and
libido which has been attached to objects is withdra%vn from them
and becomes attached to the ego.

Narcolepsy: Sudden attacks of inwistible need to sleep.

Negativism: Often used loosely for any refusal of a patient to make
personal contact with an examiner or to cany out reasonable
requests made by him. Kleist used this term for active resistance
to all interference.

GLOSSARY

269

Neurasthenia: Literally ‘tired nerves’. First applied to neuroses in
which the outstanding feature was fatigue. As the complaint of
tiredness may be a leading symptom in acute and chronic anxietj'
states, autonomous dysthymia, and mild coarse brain disease it is
best avoided, but it can be used on insurance certificates.

Neuron: The cell which forms the basic unit of the nen'ous sj’stem.
These cells are capable of being excited by others and transmit the
excitation to other neurons.

Neuropsychiatry: A popular term in the United States and in the
British Armed Forces in World War 11, Both psychiatry and
neurology are separate specialities, the former being the more
important.

Nihilistic Delusions: The patient bclie%'es he is dead and that every-
thing around him is dead or reduced to nothing.

Object: A psychoanalytic term designating a person or thing which is
invested with libido and which gratifies instinctual urges.

Object Choice: A selection of an object in the psychoanalytic sense.

Object Libido: The energy of the sexual instinct which is attached to
obj’ects.

Obsession: A content of consciousness which cannot be got rid of,
although when it occurs it is judged to be senseless or at least as
domiruting without cause. The essential feature is that this
experience occurs against the patient’s will, but it is recognized
as his own thought. A compulsion is the motor expression of an
obsession.

Obsessional State: An illness characterized by severe obsessions.

Oedipus Complex: A set of ideas centring around the desire to have
Sexual relations with the parent of the opposite sex. Oedipus was
a king in Greek mythology who unwittingly killed his father and
married his mother.

Onanism: Used by German-speaking and psychoanalytic writers as a
synonym for masturbation. This shows a lack of Biblical scholar-
ship, for although Onan ‘spilled his seed upon the ground* he
was Indulging in coitus interruptus and not masturbation.

Oral Eroticism: Sexual excitement from stimulation of the lips and
mouth.

Organ Neurosis: Used by psychoanalysts as a synonym for psycho-
somatic disorders. It has dso been used for anxiety states in which
the anxiety symptoms h3\'e become restricted to one physical
system, e.g., cardiac neurosis, in which the anxiety symptoms are
held to be due to a cardiovascular disorder.

Orientation: Used in psychiatry to mean that the patient knows who
he is, where he Is, and what tune it is. This is referred to as

zyo AN OUTLINE OF rSYCHIATRY

'orientation for person, pbce, and time’. Loss of orientation is
called ‘confusion’ and occurs in organic states.

Palimpsest: See Blackout.

Paraestuesia: Unpleasant tingling sensations.

Paralogia: This term has been used for several different phenomena.
Kraepelin used it for 'tallung past the point' or Vorbeireden (q.v.).
Kleist used it for positive forma) thought disorder.

Parano/a: Ofipnaily meant delusional insanity, but Kraepelin used it
for a group of patients who had marked paranoid delusions, but
showed little in the way of p^chological disorders apart from the
delusions.

Paraphasia: A variety of speech disorder in which the subject chooses
the wrong ^vord or uses a non-existent one.

ParafiirenU: A schizoplirenic illness in which there are marked para-
noid delusions and auditory hallucinations with no gross disorder
of affective expression.

Paresk; Weakness of a muscle or group of muscles.

Parkinsonism: A syndrome due to disorders of the basal ganglia,
consisting of rigidity, tremor, a mask-like face, and a posture of
slight generalized fle-tion. A re>'eTsibIe Parkinsonism, known as
’pseudo-parkinsonism', is produced by phenothiazines, reserpine,
holoperidol, and other tranquillizers.

PASsm Algolagnia: A synonym for masochism (q.v.).

PATitOCENTC: CausaU've of disease.

Pathognomonic: Characteristic of a pven disease.

Pathological I.vrotiCATio.v; A tivilight state with tvireme violence
which occurs after a slight to moderate intake of alcohol in the
absence of the signs of drunkenness. The patient has no memory
for the episode.

Pathoplastic Factors; Those factors which modify the clinical
features and the course of UIncss and arc not directly rebted to
the psychological disorder.

Pettic Ulcer: An ulcer occurring in the stomach, In the first part of
the duodenum, or in any plan where there is gastric mucosa.

Pebso.va: The part of the mind which the individual presents to the
world.

PFROpniEBEPHRENiA (PpROPFsaiizoPHRENiA): Schizophrenia occurring
in a mental defective. Also called ’grafted schizophrenia*, which
is a direct translation of thb German term.

Phallic Phase: The last stage of infantile sexual development when
sexual exdtement b centred on the genitab.

Phantom Lisib; The sensation that the limb is present after it has
been amputated. Sometimes very painful.

GLOSSARY

271

Phenotype; The total characteristics of an organism which are an
expression of its genetic constitution. Because of the dominance
of some genes, the presence of genetic modifiers, and chance
factors, the genetic constitution can only be partially expressed in
the phenotype.

Phobia: A morbid fear. There are three varieties: (1) Conditioned
phobias -which are learned in childhood; (2) Obsessional phobias;
(3) Hysterical phobias.

Pleasure-Pain Principle: Freud postulated that the id tended to try
to avoid pain and to gratify primitive impubes with no considera-
tion for reality.

PosT-TRAUMATlG Amnesia: Lqss of memory following injury to the
br^n. The duration of this amnesia is directly proportional to
the severity of the brain damage.

Primary Delusion: A delusion which cannot be derived from some
other psychological event. (See Apopjiany.)

Primary Gain: ^Vhen a conflict is partly solved by the production of a
hj’sterical conversion symptom there is some relief from anxiety,
50 that there is a primary gain from the hysterical illness.

Primary Process: The direct expression of the unconscious instinctual
drives. It is illogical and disregards space and time.

Process : Schizophrenia produces a sharp break in the natural develop-
ment of the personality in the same way as an organic process
afiecting the brain. This has led to the assumption that schizo-
phrenia is due to some organic process affecting the finer mechan-
isms of the brain. Different authors have claimed that different
groups of symptoms are ‘process ^mptoms’ indicating an active
schizophrenic illness. In American literature the term ‘process
schizophrenia* is used to indicate schizophrenia which leads to a
deterioration of the personality.

Process Course of Illness: The type of schizophrenia which runs a
steady downhill course.

Process Schizophrenia: See Process.

Prodromata: The initial signs of illness which occur before the patho-
gnomonic signs.

Projection: A mental mechaiusm whereby repressed unwanted ideas
and attitudes are attributed to others.

Projection Test; A test in which incompletely structured material is
presented to a patient and he is required to describe what he sees
or to construct a story based on the* material.

Pseudodementia: See Ganser State-

PSEUDOHALLUCINATIONS: Hallucinations which lack the lively character
of perceptions and can be distingubhed from real perceptions.

272 AN OUTi,t«t U»

PsEUDOLOClA Fantastica: Fantastic Ijnng by appreciation-needing
(hysterical) psychopaths.

Psychic Reality: Reality as it appears to the patient.

PstaiOANALYSis: Originally a sp«^ technique of psychological treat-
ment based on free assocLatton. It also means the theories elabor-
ated by Freud and his follotrers.

Psychogenic: A disorder produced by psychological factors. It should
be noted that not all psychogenic ^sordera are hysterical since
this latter term implies the presence of unconscious motivation.

Psychogenic RcAcnoNt A reaction of an individual to psychological
trauma. The sj’mptomatology nill depend on the personality, the
intelligence, and the social t^ckground of the individual and on
the nature of the trauma.

Psychopathic Disorder: This is defined by the Mental Health Act,
1959, Section 4, paragraphs 4 and 5, as follows: —

*(4). In this Act “psychopathic disorder” means a persistent
disorder or disability of mind (whether or not including sub-
normality of intelligence) which results in abnormally aggressive
or seriously irresponsible conduct on the pan of the patient, and
requires or is susceptible to medical treatment
*(5). Nothing in this section shall be construed as implying
that a person may be dealt with under this Act as suffering
from mental disorder, or from any mental disorder described
in this section, by reason only of promiscuity or other tnunora]
conduct/

ftYcuoPATHic Personality (PsYaioPATii): Most English-speaking
psychiatrists use this term for antisocial individuals who have
been emotionally unstable from childhood or adolescence, have a
normal intelligence, are only certifiably insane for short periods,
lack foresight, and fail to learn from punishment. German-
speaking psychiatrists tend to regard psychopathic personalities as
grossly abnormal people and accept Sdincider’s definition: ‘Ab-
normal personalities , . . who suffer from their abnormality or
cause society to suffer from their abnormality'.

PSYCHOSO.SMTIC DISORDERS: Often used loosely for the physical expres-
sion of psychological disorders. It is best restricted to those dis-
ordere in which psychological factors appear to play an important
part in producing a disorder of the function or the structure of
the body. If the disorder is one of funcrion it is not one which is
normally associated with emotion and cannot be imagined by the
subject.

Pysnic: A phjsique described by Kretschmer who claimed that it was
the commonest body-build among manic-depressives. TTie head

GLOSSARY

IS spheroidal, the face round, the neck short, the thoracic an^
abdominal cavities are t-olumtnous, and the limbs are well propor-
tioned and rather graceful.

Ptromania: Fire-setting carried out for pleasure.

Rationalization: The production of a rational explanation for an
emotionally determined pattern of behaviour.

Reaction: This is used rather loosely for any change in the psycho-
logical state which is brought about by external events which do
not damage the brain. Jaspers has defined a reactive psychiatric
illness as ‘One in which there is a clear relation between the ill-
ness and the alleged cause; the content of the illness is the same
as the cause, and if the cause can be reversed the illness tvill
disappear’.

Reaction Formation: This is a mental mechanism In which un-
conscious complexes are kept out of consciousness by the presence
of the opposite set of ideas in consciousness. For example, un-
conscious sexual desires may be kept In check by a conscious
prudish attitude.

Reactive Depression: This term is used by many English-speaking
psychiatrists in a rather ill-defined way. Sometimes it seems to
mean a state of unhappiness which has occurred as a response to
some psychological trauma or, in other words, excessive normal
unhappiness. Sometimes it seems to mean a depressive illneas
(autonomous dysthymia) which has been provoked by a psycho-
logical upset.

Recessive Inheritance; This is when the manifestation of an inherited
character does not occur unless members of the given allelo-
morphic pair of genes are identical. This means that the affected
person must receive a similar gene from each parent, so that dis-
orders with a recessive inheritance appear in a sibship and affect
one-quarter of the offspring of the union.

Reduction Division: The dirision of the precursors of the sex cells,
ovum, and spermatozoon, in which the number of chromosomes
is halved.

Regression: This occurs when the organization of the mind passes
back to a level corresponding to an earlier stage of development.
In psychoanalytic theory this is brought about by introversion
(q.v.) of libido, which activates the more primitive levels of func-
tion.

Repression: An unconscious mental mechanism which prevents ideas
and affects from becoming consdous.

Resistance: The unconscious opposition to free discussion of psycho-
logical problems during psychotherapy.

V.

274 an outline of psychiatry

Retrograde Aainesia: Ixjsa of memory for a period preceding an
injury to the br^.

Ritual: Compulsions carried out in a rigid set vray.

Sadism: A sexual perversion in which sexual enjoyment is obtained
from the infliction of pain and degradation on the love object.
Also used very loosely to indicate the enjoyment of the physical
and psychological suffering of others.

Schizoid: This term means ‘resembUng schizophrenia* (q.v.), but is
particularly used as an abbreviation for 'schizoid personality’.
This indicates a shut-in withdrawn person who is more interested
in his inner fantasy life than the real world. Kallmann has claimed
that the schizoid is the heterozygote for the schizophrenic gene,
while the schizophrenic is the homozj'gote. This « not in accor-
dance with the facts.

ScillzoPHASlA: A variety of schizophrenia in which there is gross
speech disorder which is often in marked contrast to the intelli-
gence shown by the patient’s general behaviour,

Sciiizowirenja: A group of mental disorders in which there is no
coarse brain disease and in which many different clinical pictures
can occur. The form and content of the symptoms cannot
be understood as arising emotionally or rationally from the
affective state, the previous personality, or the current situation,
with the proviso that paranoid delusions are not diagnostic of
schizophrenia in the absence of other clearly non-understandable
symptoms.

Scoptophiua: Sexual enjoyment from watching nude men, women,
or children, or from watching normal or perverse sexual activities.

Secondary Gain: The disability produced by a psychological illness
may lead to environmental changes which are advanugeous to
the patient, so that, apart from the primary gain produced by the
neurotic solution of the conflict, there is a secondary gain due to
favourable fortuitous changes in the environment.

Secondary Processes: These are the processes used by the ego to
deal mth the demands of the real world and to modify the de-
mands made by the instinctual drives. They are therefore based
on lo^cal tWnUng in contrast to the illogic:d pictorial thinking of
the primary process.

Severe Subnor-mality: The English legal term for severe mental
defect Defined as: *A state of arrested or incomplete develop-
ment of mind which includes subnormality of intelligence and b
of such a nature or degree that the patient is incapable of living
an independent life or of guarding himself against serious exploita-
tion, or will be so incapable when of age to do so’.

GLOSSARY 275

Sopor: A state of marked drotvsiness in which the patient can make
purposeful reactions to some stimuIL

Stupor: A state of motor inacthri^ usually assodated with mutism or
diminished verbal responses.

Subconscious: An unsatisfactory synonym for the unconsdous (q.v.).

Sublimation: A mental mechanism in which there is a desexualization
of the instinctual energy which is then used to support non-
sexual drives.

Subnormalitt: The English legal term for moderate mental defect.
It is defined as; ‘A state of arrested or incomplete development of
mind (not amounting to severe subnormality) which includes sub-
normality of intelligence and is of a nature or degree which re-
quires or is susceptible to medical treatment or other special care
or training of the patient*.

Superego: This is the part of the mind which imposes a moral censor-
ship on the ego. It is formed in childhood by the child taking
over what he considers to be the parental attitudes, so that the
attitudes of the superego are often very severe and punitive.

Symbolism: An illogical variety of thinking in which symbols are used
in a concrete way.

Syndrome: A group of symptoms and signs which tend to occur
together and which are probably the expression of a disorder of
function produced by one or more disease processes.

Tkougkt Disorder: Sometimes used loosely for formal thought dis-
order (q.v.); but there are three other forms of thought disorder,
namely, disorder of the stream of thought, the possession of
thought, and the content of thought.

Thyrotoxicosis: Over-activity of the thyroid gland causing over-
activity, tremulousness, loss of weight, and a hot moist skin.
Thought to be a psychosomatic disorder (q-v.).

Transexualism : The delusion that the subject has the mind of the
sex opposite to his or her anatomical sex.

Transference: The transference of an emotional attitude towards some
important person in the individual’s childhood on to someone else
with whom the individual comes into contact. This particularly
occurs in the treatment situation when the patient identifies the
therapist with a parent or parental figure.

Transvestism: Sexual enjoyment from wearing the clothes of the
opposite sex.

Traumatic Neurosis: A neuroris occurring after severe physical or
psychological trauma. A useless term, best avoided.

Trisoniy: Owing to faults in reduction division (q.v.) a germ cell
may contain a pair of homologous chromosomes (q.v.) instead of
18*

27b AN OUTLINE OF FSTCHIATRY

the usual one. If this cell fertilizes or is fertilized by a normal sex
cell then the ne\v individual will have three chromosomes instead
of the normal pair. This is trisomy, and trisomy of the twenty-
first chromosome is responsible for many cases of mongolism, a
form of mental defect

Twilight State: A condition in which there is a restriction of con-
sciousness due to coarse brain disease or anxiety.

Ulcerative Colitis; Ulceration of the lower part of the bowel of un-
certain origin. Often claimed to be a psj'chosomatic disorder
(q.V,).

Unconscious: The Freudian unconscious is that part of the mind
which cannot normally be made conscious. It is composed of the
id (q.V.), a part of the superego (q.v.), and repressed material
which has been conscious but has been pushed out of conscious-
ness.

Uniovular Twins: Ttvins who have developed from the same ferti-
lized ovum which split into ttto separate parts after the first
division. These twins have exactly the same genetic constitution,
so that if an inherited defect occurs in one, it should occur in the
other.

Urethral EROnastt : Sexual enjoyment from the act of passing urine.

Vorbeiresen: Talking past the point The patient gives approximate
answers which show that be has understood the questions put to
him and knows the correct answer. {See Ganser State.)

Voyeurism: A synonym for scoptophilla.

Withdrawal Syndrome: In dnig addiction there is a pfaj-sical change
in the nervous system so that the normal functions cannot con-
tinue without an adequate intake of the drug. If the drug is with-
drawn symptoms appear which are due to the malfunctioning of
the nervous system. These symptoms constitute the withdrawal
syndrome, which may last for liouis or days depending on the
nature of the drug and the individual's constitution.

Word Salad: Incomprehensible schizophrenic speech.

277

Abnormal, meaning of term - - 63-^

Abomon, legal - - . - 233

— Art (1967) ... - 233

Abreaction ..... 218
Absence ..... 254
Absiem (tee Citrated calaum carba-

Acetylpromazine - . - • 196

Acromegaloid appearance in schizo.

phrenia ... - 127

Artomol ..... 124

Addiction (tee Alcohol addiction and
Drug addiction)

Adler, A. . . . 18,30.266

Admiuion to hospital, eompulsorr 226

— — mfotinal .... 225

— — medical recommendstions for 226

— — for observation ... 225
Adolescence, autonomous effective

ensiaof .... 234
Adolescent ensea • • 30,41,134

Adrenaline ..... 20$
Affect- . 52, 54. 88,129,254.267

— equivalents .... 88

— flattening of • - * • 129

— inadequate expression of • . 54

— incongnitff of • . *129

— lability of (tee cIm Emotional

uicontinence) ... 267

— stiffness of - • • • 129

Affective disorder, definition of . 254

— psychoses ... 113-25

— — in the aged • . 160. 161-2

— — electroencephalograph in • 240

— — puerperal ... - 159

— atatea, mixed - - - . I2I

Affecovity, definition of . .52

Age and mental illness ... 8

Aged, affective psychosis in * 160, 161-2

— artenoscIeroCic psychosis in 163-5

— classification of mental diaorders

— delinum in • - • - 165

— dementia in . . - 162-3

— paranoid atatea in * • - 166

population trends m . - 160

— suicide m - - - 164, 236

Ageing, psychology of ■ ■ . 159

Aggression .... 65, 81

Agitation in depression . .117

— ■ involutional melanchoba . • 119

— symptomatic treatment of - 192

Agnoaia . . - 41,62,254,264

Agoraphobia .... 254
Agraphia . . . 41,254.264

Aim inhibition ... 27, 254

Akineaia ... 59. 130, 254

Akinesis .... - 130

Akitbeaia - - - 137, 198, 254

Afcalculta - - . - 41,264
Alcohol addiction - 100-106. 254

— — avemon therapy in - 102, 219

biochemical disorders in - 101

causes of . - - 100, lOt

citrited calcium earbanude

treatment of - • . 102

— — definition of - - - 254

— — development of - - - 101

— — disulfiram treatment of - 102

— — personabty disorder in • 101

— — psychistric illness and • 100

— — psychoanalytical theory of - 101

— — psychotherapy in - - 102

— — social factors in • - . 100

— — treatment of - - 101-2

Alcohobc delusions of jealousy - 106

— dementia .... J06

— haOuoAosis . • . , 104

— Korsaioffslaie . . 104-$

— parsnou .... ]06

Alcohobca Anonymous - • 102

Alcoholism .... 100, 254

Aldomet (rre a-methyldopa)

Alexander, F • • - - 89

61,355

Algolagnia, tnite (irr aho Sadism)

173, 254

— passive (tee o/io Masochism) 173, 270
AU^or [tte Nortryptyline)

Allelomoiphs .... 255

Alogia 255

Alpha rhythm .... 238
Alzheimer's disease 60, 145, 154, 236, 240
Ansbitendency - - - - 55

Ambivalence - - * - 54

Amenorrhoea ... 95, 197

Amentia .... 55, 255

Aroitryptyline - - 23, 123, 203

Amnesia (res aho Amnestic syn-

drome)

9, 48. 80. 90. 101. 255, 271, 274

— anterograde - - 48, 101,255

— dissociative - - - - 48

— fayitencal * • - 48, 80

— organic ■ - - * 48, 90

— post-traumitic ... 271

— psychogenic ... 48, 80

— retrograde ... 48, 274

Amnestic syndrome

49, 104, 144, 146, 148, 1S2, 164, 255

— — ^cohobc . _ - - - 104

in arteriosclerotic psychosis . 164

— — and brain injury * - 152

causes of - - - _ . 144

— — in tuberculous meningitis • 148
Amphetamines - -23,122,194,202

278

INDEX

PACE

Amytobarbitone sodium 16S, 191, 193,218
Ainyostatic syndrome . . - 147

Anal eroticisa) . . • 26, 25S

— intercourse . 173, 178

— ssdutic stage in hbidinsl de-

velopment - . - 26 , 83

Analgesics . • . - . 106

Anankast (lee Personality, anankasoc)
Anankasac reacuoiu 0» Obses-
sional reactions)

Angst S3

Anorena » . . - 97, 255

— in depression - - - - 119

— nervosa • • . . 81,255

Anoxia ..... 4

Antabuse (ire Disuliiram)

Anticathexis .... 255
Anxiety S2-3, 72. 74, 73. 76.

78, 81, 192,255. 256

— m depreaxion ... S2--3

— elation psychosis ... 255

— hvstcna ... 78. 81, 256

physical symptoma of * - 74

— • psychological symptoms of * 74-7
~ reactions .... - 74.7

~ sleep disorders ui - • *76

— 76-7. 256

•— lymptomatie treatment of • 192
Anuoua penonality . • . 72

Apathene coofustoaal itatea • . 142

Aphuu • . 60-1, 155. 156, 256

— in Abhetmer's disease • • 155

Pick's disease .... 156

Aphonia .... 60, 256

Apotnorphine ... |02, 180

Apophaooua ides .... 256

— fflood(t(e<:/ieDeIusiatialmood)44.2S6

— perception ... 45, 256

Apophany ... 44, (28, 256

Apraxia ..... 61-2
Aneteus the Cappadocian . • 10

Archetype .... 32, 256

Argyll Robertson pupils • • 149

Artenosdeiotic psychosis

114, 145, 160. 163.166

— — clinical picture in « 163-4

— — depression in - - . 164

— — prognosis of - - - 164

— — suicide in - - . 164,236

Arthntis, rheuimiotd - • • 98

Assault ..... 65

Asthma, brorichisl, factors iaflu-

enang - • - * . 91

— — personality theories of • 92

Asyndetic thinking - - 47, 256

Aurax (r« Hydroxyzine)

Atropine poisoning, dytmegalopiia

— — visual hallucinations in • 206

Attention ..... SO
Aura ..... 41, 256

Auwra - - - - 130.256

Autuac thinking ... 42, 256

Autochthonous idea ... 45

Auto.eroticiani (see alto Masturba*

tion) .... 177, 257

Auremauc obedience ... 57

Automatism, command . . 57

— post.epiteptic - • - ISO

Autonomous dysthymia (set o/iotlb

Depression) ... 117,237

Aversion therapy in alcohol

addiction .... t02

— — in sexual penetsion - - 180

Aventyl (i« NortO’ptybne)

Avicenna • • • - • It

DaiiXABcan, ]. .... 14

Barbiturate - 33, 85. 110, 191-2, 193

— addiction - * . - HO

— hypnotic eifecta of • . .193

— aeditive etfeets of • • 191-2

— aleep in animal neurosis . • 33

Bajde. A. L. J. . - - - 13

Behaviour, abnormal patterns of . 58

— disordtf of, m acbixophrems . 130

— EoalHlirected .... 59

— immoral - 59, 172, 225, 272

— mannenitic .... 59

— mbitctive experience of - .53

— tlierapy ..... 219

BtUe,„Mirts>et - . 54,79,257

Bell's nui^ . - - .257

‘Bender’, alcoholic ... 2f7

BensedKne (see Acnpheutnines)
Benatropine methanesulpbonaie • 125
Bereavement as a causa of deprea.

aton ..... 116

Berehaim, H. - * - > 17

Bestubty .... 176,257

Beta rb^hm .... 238
Betblem Hospital • • 18, 20

Bic6tre ..... 12

‘Binge-aatuig syndrome' . . 97

Bull, t. - - ... 22

Bcsexuiliry ..... 257

Blackout . . - . so, 257

Blculer. E. 16

— M. 127

Bodily sensauon, diioniet of . » 41

Body image ..... 257
BonhoeiTer, K. - - - - 16

B661i.; 3

Boatroem, A. - - - - 149

Bradyphrema .... 257

Brawl./ 12. 17

Bnin disease, psychiatric illness in

(lec 0(10 Organic atates)

1)4.13.16,139

— inyuiy, psychiatric sequelae of 152—1

— tumours ... • 158

— washing .... - 34

Bristol Royal Infirmary . . 19

— distribution of achlxophrenis in _6

Bmadmoor ... - - 257

— patient ..... 230
Broca's area .... 257
Bromides in tmtmnit of animal

Bromisra .... 41,258

Bcutslity - • - • • 5?

Burckhardt, G. - - - • 22

Butyrophenonct . « •• *195

INDEX

Calmeil, L. F. - - - » 14

Cameron, N. - • - « 47

Camphor, fits induced by ■ - 22

Cancerophobia, incorrectness of ^

Cannon, W. B. - - - - 89

Carbon disulphide poisoning - 143

— monoxide poisonmg - » 143

Carbromal - • - - » 194

Cardiospasm - ... 89

Castration anxiety - • . 26

— — in sexual oiaordera

169, 172. 174, 175, 176, 177, 179
— ■ complex «... 258

— in treatment of sex offenders 182

Catalepsy .... 58, 258

Cataplexy ..... 258
CtUTtctexiiBCtioa, deliriumfoVow.

Catathyniic crisis . . _ . 234

Catatonia, abnormal movements in 56-7

— mutism in .... 60

— penodie ... - 132. 258

— ■ perseveration in • . .58

Catatonic itupor .... 143

Catharsia ..... 258
Cathexit ..... 258
Cavodii (r« Phenipriane)

Cerebral tumour .... 158
CerletD, U. • - • • .22

Character aeurosis • • 18, 28, 73

Charcot, J. M 17

Chicago, diatnbution of schiro*

pnrenfa ui • • - • 5

Child development. Adlenan theory
of ..... 30

— — Freudian theory of • 26-30

Child-beanng, psychological ill.

nesses connected tvitn - .158

Chl(^ hydrate .... 194

— — addiction to • • • 194

— mixture - ... - 191

Chlordiaxepoxide > • 192,201

Chlorpromaiine 125. 137, 191, 192. 196

Chlorprothixine .... 207
Chromosome .... 258

abnormalities ... 4, 275

Circumstantulity .... 43

Citrated calaum carbamide . . 102

Civil law, mental illness and 228-30
Clang assodatiDn . . - 42, 258

Classification of mental disorders 63—4
Climatic conditions and mental il].

Clouston, T. • - . 19, 160

Cwame addiction ... 109

— ‘bug’ - - ... 39

Cogentin free Benztropine methane-

tulpbonate)

Coitus *^ .... 167. 16S

— interruptua ... 170, 258

— reaervatus .... 258

Colitis, mucous .... 93

— ulcerative ... _ 94

Collective unconscious - - - 258

Coma 259

— insulin .... 21—2, 209

Community, Mental Health Ser-
vices and .... 190
Compensation neurosis • * 81

— prognostic importance of, in

hysteria .... 82

Complaint, to define ... 184
Complex ..... 259

— castration .... 258

— Oedipal .... 26, 30

Comprehension .... 50

Compulsion ... 43, 259

Concordm (tee Protryptyline)

Concrete attitude ... 259

Condensation ... 24, 259

Conditumal reflex . - 32, 259

Confabulation . . 49, 105, 259

Confusion .... 50, 259

— psychosis .... 259

Confiumnal state . 150,152,259

ConnoUy, J. .... 12

Consciousness, clouding of - 51,141

— definition of - . - - SO

— disordera of - . . 50-2, 130

— • — in schirophrenia - - 130

— restriction of . - . - 51

Constipafion in depression - - 1 1 9

Constitution - - - 2, 259

Conversion hystena • - 78, 259

— reMous 34

Convulsive therapy (»ee Electro-

eonvuliite treatment)

Co-operation .... $8

Coprophagii .... 259
Coronary artery disease - • 97

Cortical analyser, Pavlovitn theory

of 32

Conico-stnato-ipinal degeneration 157
Counter-cathezis • > - ■ 27

Counter-transference ... 215
Couitof Protection ... 228
Cousin marriages, recessive illness

Ciiminal behaviour in dementia . 145

— dissociation of affect in - - 135

— Justice Act (1948) - . 67 230

(Scotland) (1949) - - 230

— Lunatics Act (1884) - - 231

— psychogenic reaction in - - 187

— responaibihty .... 230

— — diminished ... 231
Cronetsi (tee Diiulfiram)

Culpable homicide ... 231
Cufinilingua .... 260
(Orator Bonis .... 260
Cyclobaibitone .... 194

(O'clothymia - • 15,113,260

Cyclothymic personality - - 71

Dvr hospital .... 190
Death mstmct - . - - 25

Degeneration ... 14, 17

Derd vicu phenomenon - - 49

De/d ru phenomenon • - - 49

Delaye, J. D. .... 14

INDEX

Delinum in tnerioKScroUcpsvchogu 163

— lubseute - - - - 141

— tremens - . - - - 103

D«lusion(0 13, 36. 44-6, 83. 106.

118, 128-9, 260. 26S. 269. 271

— ti • cause of hallucinauon • 36

— definition of • - - 44, 260

— in depression - - • - 45

— pranaiosi .... 45

— of guilt .... 46,118

— hfpoclioodnical • . 46, 265

— insanity and .... 13

— of jealousy, alcoholic • • 106

— nihilistic .... 267

— paranoid ... 43,118

— of poverty .... |18

— primary .... 44,271

— prognostic significance of . • 13

— in schiaophrmu - - 128-9

— secondary - - * • 44

— of self-reference - _ - 45,118

Delusional capencnces, primary (ite

o/io Apophany) - . 44,128

— idea in d^ression ... 118

— — sudden - - . 45, 256

— mitidentificatioo • • • 50

— mood ■ . . . 44, 236

— perception • • « 45, 256

Delta rh)ihm .... 238

Dimew Pritau .... 14

Dementia 13,19,33,144-5,151-2.

134-8, 161-2, 240,260

— ■rteroaeletouc - • -161

— cause! of .... 144

— definition of - • • 144. 260

— eleeire.encephaIogTaph ut • 240

— epileptic • - • >131

— following briin injury • • 132

— memory m • • • • 145

— penes erition tn ... 145

— priecox ... 15, 55, 2M

— — Krsepelin's concept of IS, 19. 260

— presemle ... 154-8

— — classifieicion of - • - 154

— progressive, aetiology of - - 144

— — personality changea in - 145

— schizophrenia and - - - $5

— senile, disgnosis of - • - 162

Densoniactl theory of diseases - 11

Depersonalizstion • 54, 117,260

Depression 8. 41, 45-6, 51-6, 77,

84-5, 114-19. 134, 151.

154-6, 159. 161, 164.

171. 194-5, 213. 233.

236. 261, 273

— setioloCTof .... 114

— in Alzheimer's duesse • - 155

— inorexiiin • - • - 119

— anxiety snd ... 77,119

— in arrenoscleroac piycbons - 164

— consiipatiun in ... JI9

— delusions in - - 45. 46, 118

— in dementu - • • *145

— depersoiuhzstion in . » 117

— dilierentiil diagnosis of - - 119

— disorders of rrsctis e movemenu

tn 56

Depression, endi^noui

— in epilepsy • .

— foltoveing brsin injury

— in fneidity

— fugues m • -

— h Jludnations in .

— m Huntingdon's chorea

— hypoacusis in •

— intellectvul performance it

— leucotoBiy in -

— murder in - .

— neurotic - .

— and obsessional ttatei

— paranoid

— perplexity in -

— in pregnancy -

— provoked •

— puerperal - .

— teserpme-indoced •

— treatment of • . » 194-S

Depressive position ... 29

— reactions .... 8$

Derealiunon .... 260
Detcistie thinking ... 260
Oewnipremine .... 122

Detrnoranon. sehizophremc > 55, 126

Deairo.amphetamiBe sulphate 122, 194

Diabetes mellitus .... 95

Diagnosis, psyeboarielyslt end • 187
Diemorphine (ler Ilertnn)

Diairboet, nervous . . . gq

Diaxrpsm .... 192, 201

DKhloralphraszone ... 194

Dimcrphslon .... II5
Dunrdiyltrvptamine ... 109
Diminisbcd responsibility, pice of 231
Dinoestrol ..... 181
Dipsomsma .... 260

Diiipal <tre Orphensdnne bydro-

cMonde)

Disoneotsuon foe person • • 50

— tune and place . . 50, 105

Displacemem - . 24, 27, 260

Dissoasnon ... 79, 260

Distrectsbility .... 75

Duulfirem - - . . • 102

Diwstee end inssruty ... 229
Dole, V. P. • - - - - 108

Dominant inhentince ... 260
D^pelglnger .... 38

Dormeo (ut GlurelJiimide)

* Double.bind ’ technique 127, 169, 186
Dreams, rreudian theory of • - 29

INDEX

281

Drug iddjction, personality types tn 111

psychological theone* of - 111

social factors m • • - 112

— — 8>mptom8 dunng • - 106

— — Wilder's pharmacodynamic

interpretation of - - 111

— dependence .... 100

Duncan, A. .... 19

Dysmegalopsia ... 40-1

Dysmenorrhoea ... 95-6

Dysmnesic syndrome ... 261
Dysphasia - - . . • 261

DysplaSDC physique - - 136, 261
Dysthymia .... 151, 261

— autonomous (lee alto Depres-

sion) - .... 85

epileptic .... 151

ECHOLALIA .... 155,261

Echopraxia .... 57, 261

Ecstasy ..... 261
E.C.T. (see Electroconvulsive treat,
ment)

E E G. (lee Electro-encepbalograph)

Ego .... 25, 30. 261

EJacuIttio ptaecos
~ retardata . . .

Elation . . . .

Electroconvulsive aestmant

165, 199, 210-12,261

— — m artenosclerotie psyehost* 165

contra-mdicationi to • • 212

— — m depressive diseue • • 124

— — histo^ of • • • * 22

— — indications for - - • 212

— — in mama . - • • 125

— maintenance ... 212

— — memory disorder in - * 211

— — reserpine and - - JS8, 199

— — in schizophrenia . • . 137

— — techiuoue of - • 210, 261

Electro-encephalognph

110, 150, 151, 238-40

— abnormal .... 239

wave forms m -

— in abstinence syndrome

— affective psychosis •

— dementia

. 239

- no

. 240

- 240

— epilepsy - . 135, 150, 151, 239

— in neurosis .... 239

— normal

239

— phase resersal in

— in schizophrenia

— subdural haematoma

- 238

- 240
133, 135. 240

- 153

Electronarcosis .... 212

Electroplexy (tee also Electro*

convulsive treatment) . 212,261

Emotion 52-5. 145, 155, 130, 162, 261

— definition of * - • S2 , 261

— disorders of - • - 52-5

Emotion, disorders of, in Alzbeimer'a

^sease ... 145,155

— — arteriosclerotic psychosis 145, 155

Pick's disease ... 155

schizophrenia - 52, 54, 130

— — senile dementia - - 162

Emotional incontinence . • 54, 261

— indifference ... - 54

Empathic psychology (see Psycho*

logy, understanding)

Empa^y ..... 261
Enccphabus .... 14$

— kthargica .... 148

Encephalopathy, traumatic • - 153

— \W;micke’8 - . . lOS-6

Endocrine disorders

8-9. 94. 114, 127, 179

— — in fngidity ... 171

— — homosexuabty ... 179

— — impotence ... 169

— — manic-depressive disease • 114

— — schizophrenia - * •127

Endogenous depression (ree De*

pression, endogenous)

Engagement neurosis ... 81

Engel, G. L. * • * - 94

England, cnminal responsibility in

230-2

— hospital admission in - 225-7

— legal abortion in • • • 233

— — definition of mental illness

— murder in • • • 233-5

^ old age in .... 160

Enuresis . . . . • 219

Environmental factors in alcohol

addicBon .... 100

— — drug adietion • • - 112

— — achinphrenia ... 5.^

Epilepsy 4, h, 41, 59, 150.1, 153,

164,235,266

— aura preceding ... ISO

— aulomstism in ... 150

— confusional sutes m • - ISO

— dementia m .... 151

— dysmegalopsia m - * .41

— dysthymia in .... 151

— electro-encephalograph in

135, 150, 151,239

— excitements in ... 59

— fbe^ ..... 266

— Mkiwing brain injury - - 153

— hailucmations m * - * 38

— ictal moods in ... ISO

— Jacfaonian .... 266

— murder in * * * - 235

— paranoid psychosis in • - 151

— petsonali^ change in - 4, 151

— piycitinifirnr attarka in * - 150

— and schizophrenia * - 22, 135

— achizophremc-Uke psychoses and ISl

— suicide and ... - 152

— temporal lobe ... 151

— twilight sutes in - - - J5t

— uncinate fits in ... ISO
Epileptic fits m Alzheimer’s disease 1 55

— — artenosclerouc psychosis - 164

282

INDEX

Cpileptoid perionAlity • • - 68

Eqiunil {ue Meprobatmts)

Enbion, £. H. - • - • 30

Eroa ...... 2S

Erotogenic aonee .... 262

Erotomania ..... 87

Esqulrol. J. E. D. . . • 13

Ether, abreaction with - - - 218

Ethinrloettradiol .... 181

Ethology ..... 5

Euphoria . 53, 77, 105, 158. 162, 262

— in amnestic tysdmme - • 105

— dehmtion of • • - S3 , 262

— in hepatolenticular degeneration 158

— aemle dementia - - - 162

Euphonanta ... 106, 109

Eutonia ..... S3
Eicitement(a) 39, 80, 120. 130, 191-2

— brstencil .... 80

— manic .... $9. 120

— achiaophremc - - . 59. 130

— treatment of ... 191-2

Eahauauon and mental lUneu « 9

Etthibioomam • • 174-5.262

EsutentiaUsm .... 262
Eiprettive moyemenu. disorder* of 56
Eatrapynmidal ditotden in Jakob

Creueafeldt diseaae « « 157

Extras eraion ... 31,262

Fauht, J. P. . . . *14

Famaay ..... 28

Fana, K. E. L. • « • • 6

Fear, inaicij and ... 53

Feeling, deftmuon of • • « $2

— disorder! of (ue Emotion, dia*

orderi of)

Fellatio ..... 262
Femche!, O. .... 89

Fcntazin (>ee rerphenazme)

FcQshum ... 173, l76, 262

Finger agnosia ... 41,254

Fish, F 98

Fixation ..... 262

— point in drug addiction • - 111

manic-depressive disease 115-16

— — psychosomatic disorders - 90

Fiexibilitas cerea ... 58, 263

Flight of ideas . 42,115, 120.263

Fluphenazine ... 192,198

Fo/iedJeux . - . - 263

— d double forme ... 14

— areulaire .... 14

Forced grasping .... 58

Forepleasure .... 263
Formal thought disorder ($ee

Thought isorder, formal)
FomicsQon .... J09
Freeman, W. .... 23

Fright reaction* ... - 71

Frigidity ... 170-1,263

Freud, S , defence mechanisms of 28.116

— — historyofpsychotherapyand 17-18

— — theory of psychoanalysis of 24

Fteiul, S , theory of. dreams of . 28

— — — instincts of . - - 25

— neurosis of - - - 28

— — ~ unconscious of . - 24

Fnmtal lobe leaions, aphasia in . 61

“ — syndromes ... 146

Fugue • • - 51,80,263

FiJton. J, F, - . . -23

Functional, definition of - - 263

— psychosis ... 64, 263

Furcht _ - _ - - » - S3

Furore, epileptic . . - « 59

‘Calknia humour* ...
Ganser atates ... 80,

Gene .....

Genera] hospital, psychiatric units

— paresis <0 P.I.)

13-14.21,46, 148-50.264

— — mndiose delusions in . 46

— — history of • - • 13-14

— — jinenile .... JSO

— — Lisssuer’s type ... 149

— — malarial therapy of - > 21

— — mood in . » - » 149

— ’ — symptoms of » • • 149

— — treatment of - • - ISO

Ceneoe cosstitution • • > 2

— factors in Alabeimer’s disease ' 154

— — hrpitelenticMltr degtnera*

— — inarue>depreisiye disease 4, 114

— — Pick’s disease • • • ISS

— — schizophrenia - • 3, 126

Genotype ..... 264
Gerontophllit .... 176
Gerstmann's syndrome - 41,264

Gressing, R. - • - 9, 133

Globus hystencus ... 264
Clutethimide .... 194
Go«!.direeted motemenli, dis-

Goldstein, K., concept of o
attitude of -
Goltz, G. - -

Grandiosity

Crisp - . -

Graves' disease .... 94

Cnesinger, W .... 14

Group therapy .... 216

Guardianship . - 67, 227—8, 264

— le^ procedures for • 227-8

— and psychopath ... 67

Guilt, detusioni of ... 46

'Cuilcybutinsane' * - 230-1

INDEX

283

HaIIucin2tion(t) 3, 5, 13, 36~7, 38,

40. 81. 103, 118,

129, 146, 151, 264, 267

— auditory - 36, 103, 118, 119, 150

— — tlernenUry - . » 36

" — organized (phonemes) 36-7

— in delmum tremens - 103

depression - * - II8

— — — epileptic psychoses - ISO

— schizophrenia - - 129

— causes of 36

— of deep sensation - - . 39

— in dementia ... 146, ISI

— depression - - - - II8

— elementary - - - . J29

— eitracampine . • - - 38

— functional .... 36

— hypnagogic ... 35, 264

— hypnopompic - - 35, 264

— LiUiputian ... 103, 267

— in mama ■ - - . |20

— mas

— olfactory . ... 38

— patient’t attitude to . . 39

— pseudo* - - • 35, 271

— reflex . - - . . 39

— m schizophrewa ... i2?

— aezual ..... 39

— tactile ..... 39

— — in cocaine psychosis

39, 103, |M

— — delirium tremens • • |03

— — scbuophrenia . • 28, |29

— of taste • .... 38

— vestibular sensation . . 39

— Tisual . - 37-8. 51. 142. 143

m delirium tremens • 38, 103

— — epilepsy ... 38, 1*1

— — hysteria .... 81

— — schizophrenia - . 38, 12^

Hsllucinsiory syndromes • *

Hallucmogcnic drugs, addiction to 109

Hallucinosis • 40, ICM, 143,264

— alcoholic ....

— confusional - - - - 40

— fantastic .... 40

— organic - ... - 143

— aelf.refeiencc - - . - 40

— verba] ----- 40

Halopendol . - 125,138, 199

Hamvell Asylum - - - . 12

Hare, E. H ... - 6

Harlow, H. 5

Hashish 109

Haslam. J. - • - - - 18

Hay fever ..... 02

Head injury, psychiatric cffecis of 152—4
Hearing, distorliona of - • - 41

Heautovcopv ... - 38

Hebephrenia {see also Schizophrenia,

Hecker, E. -
Hemi-anaesthesia
Hemiparesis . - -

Hemiplegia - - . -

Henderson, Sir D. K. - _ •
Hepatolenticular degeneration

Heroia addiction . - . . 103

Herxheuner, H - . • .91

Heterosexuality .... 264
Meterozygote ... 3 264

Hill, C. 12

Hippocrates . - • .10

History-taking, scheme for - 241-2

Homiade Act (1957) - - . 231

Homosexuality - 101, 169, 177-80, 264

— aversion tnerapy in - - 219

— childhood seduction and - . 179

— endocrine disorders and - - 179

— female - - - . - jgo

— Kinsey'a clasiiflcahon of - 177-8

— latent, in alcoholism . • 101

impotence ... 169

— male .... 377-80

— psychiatric disordera and - - 178

— paychodynamic theory of . 179

— psychotherapy of ... 181

— social aspects of - • - 180

— treatment of - - . 181-2

Homozygote - - - 3, 264

Hormones ..... 94

Hunnngdon’a chorea • 3,145,156

genetics of * • 3, 156

— — spontaneous movements in

57, 156

S.hvdrozytryptamine * - 205, 206

Hydmy^e .... 2OO
Hypertcusis .... 41

Hy^remesis gravidarum • 158-9

Hyperiuneiis .... 264
Hyperphagia .... 97

Hypersomnia .... 51

Hypertension .... 264

— essenoil - - . 97, 262

Hypettbyroidism ... 94

Hypno-sedaiives .... 200
Hypnosis, history of • • - 17

— in ptyehotherspy • > 216-17

— technique of .... 21?

— use of 217

Hypnotic drugs - - • -106

— (phasic) states - - - 33

Hypochondriasis - • 85-6,118,265

— m depression - - . . 118

Hypomarua ■ • - 120, 172,265

Hjpomamc personality • • 72

Ilypothalamua, psychological symp-
toms due to lesions of 51, 52, 53, 115

Hypothermia - - . . 265

Hystena 10, 33. 54, 60, 66, 69,

78-80, 82, 256, 259, 265

— aetiology of - • - *78

— anxiety - - - 77, 78, 256

— aphonia in - - - - 60

— conversion ... 78, 259

— diepemnaUutino. la - - 54

diagnosis of * . - 79-80

— disseminated sclerosis and - 79

— Freud’s theory of - - - 79

— halhicinations in * * - 36

— Janet's theory of dissociation of 79

— mental symptoms of - - 80

— motor symptoms of • - 80

— mutism in - . - - 66

284

INDEX

HyKena, origin of term » • 10

— parental influence on - - 78

— Pavlovian theory of - • 33

— prognoaia of - - - 82

— aensory aymptoma of • ^ 80

— treatment of • • - -82

Hysterical peraonafity . . - (9

— reactions ... 73-82

Iatfocenic, definition of - • 265

Ictal, definition of - • - 265

— moods • - - . . l$0

Ictus 265

Id 24.265

Ideas of guilt - • • - 118

— oyervalued • • • 44 85

— of persecution - 86.118

— lelf-reference . . 45. 118

Identification • • 27. 30. 265

Idiota ...... 265

million .... 35, 265

Imago ..... 265

Imbecile 265

Inupwmine 122. 162, 187. 202. 205. 265

aide (fleets of ... 122
Immignnta. sebiiophrema in « 6

Imtnoril conduct, psycfionchicdis.

order and • . 59,225,272

Impotence, drus-mduecd • • 197

— physical eiusee of . . . 168

^ paycholoicteal cauaei of • • 168

treatment of ... . 109

— vanenea of • • - - 168

— naoua circfe in . . . 169

Impreasibibty, lots of • * 49. 165

Impulsive sett .... 59

Incest ..... 265

— tsiihei . • - . . 26

Incoherence ... 43. 265

Incontinence . • 117.130

of faeces • ■ 59. 130. 16)

Indian hemp .... |09
Indigestion, nenous ... 89

Individual psychology • • 30-1. 266

Infinnade ..... 2)2

I Qglis paired.assoeute test • - 246

‘Jnsace on arraignment' • - 2)0

Iniaruty and mimige ... 229

— induced ..... 266

Iniigbtin fteurosu and psychosis - 63

- Insomnia - 52, 97, 1 19, 120, 192-3

— tn depression ... 52, 119

— mania ..... 120

— rclaiauon therapy for . - 193

— treatment of . . . IK— 3

Instincts, Prtudiin theory of - 25-6
Inshrure of Psychiatry, llniyerarry

of London • • . • 20

InstieatMOtl et!9 . . 187-292

Insulin coma therapy, history of - 21-2

— indications for . . 209

— — — tnodified ... 210

— — — in schuophrcnia • • 137

Infegnn free Orypertme)

Intelligence, disorders of . - 85

Interpenetration of themes • . 47

lotertwirung • • - . 57

Interview, method at • - . 183

fnerojection - * - 27, 266

Intrtivrmon .... 266

— Freudian - - • - 28

— Jungian - - - - • 31

Incrtisert ..... 266
Invert .... 167, 266

Involution ..... 266
Icisofutional melancholia • 119,266

Ipnndole - ' • • >123

Iproniazid • • - • . 23

imtabiliiy * - - • - 53

‘Imiable colon syndrome' . . 93

Isolation - * - - 27, 266

Isoniaaid - - • • . 23

jaexsos, D, • - - 3, 127

Jacobsen, C F - - • .23

Jalob Creutzfeldt disease . 157, 266

eteeiro.encephalogTaphin 240
James, I - * - - - IJ

Jealous husband tyniirome 96, 106, 235
— — — murder in • • « 235

Jealousy, morbid • > • 86

Jelliftelt's stem in progrtai «f

alcohol addiction « • .101

Johns Hopbns Unis-miry • • 20

Jotdanbum Nerve llotpital • . 20

Juog.C C, ... 18,31

Kaiobai'm. K. L •• - - IS

KaUmann. F J. - - • 3, 178

Kayscr-Fleiacher nng ... 157
ICey exprnence in paranoid states - 1)3
Kinsey's cbsiificaiion of bomo*

sexuality ... 177-8

Klein. M 29

Kleist, K. - - - - 16. H3

Klinefelter ajTidrome ... 4

Koch. J L A . . • .17

KonakofTe ptythoiii - - 105, 266

— state (syndrome) - - lOt-S

KraepeLn, E • 15-16,121.133,160
vmi Knft-Ebing, B. - - - 14

Kretschmer, types of physique t>f - 114
Knnaleis. £. .... 3

LA.vc’a theory of homosexuality . 179
Largactil (tee Chlorpromazine}

Laioxyl free Amitryptylme)

Latency penod • • 26, 30, 267

Ltg*} rf*poT>tibihr^ la eiTj} hw . 228

LeonJiaru, K. - . * 65, 113

— . — clajiificauon of abnotmtl

personalities of - 6S-72

Leptosome ..... 267
Lrarotomy, bimrdial . - >213

— blind rostral .... 213

INDEX

Leucotomy, prefrontal 23, 85, 124,

138, 162, 213-14.267

in depressive disease - 124, 213

history of - - - - 23

— — in obsessional states - 85, 213

— — schiaophrenia - - 138, 213

senile depression - - 162

technique of - - 213-14

Libidmal development • • 18, 25~6

“ — anal stage of - - - 26

— — latency period of • . 26

— — oral stage of - - 25

— — phoUic stage of - - - 26

Libido - - - - 28. 267

— release of .... 28

Libnum (lee Cklordiazepozide)

Liibault. A. A 17

Life style - .... 30

Lima, A. ----- 23

Lithium - - . • . 12S

Lobotomy (see also Leucotomy,

prefrontal) - • . • 267

Local Health Authonty • • 224

Logoclonia - - . £0, ISS, 267

Lysergic aeid diethylamide - 109, 206

— - — • — therapy ... 218

McNacktzn rulea - • -231

MscTop*\« .... 40, 267

‘Magnet reaction’ ... 58

MajeptJ (ter Thiopropertaine)

Matanil treatment of general paresis

21. 149

Malingering .... 80

Mammillary bodies, lesions of • 105
Mama d poiu .... 267
Mama. BeU's . . . .257

— excitement m - . *120

— grandiose delusions in - . 120

hallucinations in ... 120

— mood in ... 53, 120

— paranoid ... 54, 135

— psychoanalytic theory of - - 116

— treatment of • - - - 125

Manic-depressive disease

4, 6, 16, 38, 113-25,

135, 191,194,212,213,236

affective psychosis and - 113

basic personality in • - 114

biochemical abnormalities in 115

class distnbutton of - . 6

— — depression in {see also De-

pression) . - 117—20

— — distnbution of - - - 6

hallucinations in . 38, 39

heredity and - - 4,114

— — involutional melancholia and 119

Kraepehn’a concept of 15-16

_ mama m {see also Mania) 120, 135

physical constitution and - 114

— — prognoais of * - - 121

psychoanalytic theory of - 115

psychotherapy and - - 121

— — reactive factors in - . 115

social factors in - - - 114

suicide in . . - 118 236

Manic-depressiie disease, sympto-
matic treatment of- - - 121

— — symptoms of - - 117-20

treatment o£121. 191, 194.212, 213

Mannerism . - • - - 267

AIan;uana ... - - 109

Marnsge and insanity ... 229
Masculine protest • - - 31

Mssochism ... - 173, 267

MastuAation ... 177, 267

Maternal deprivation as cause of

mental illness - - - 5

Matnmonial Causes Act (1965) • 229

Mattissek, P. .... 167
MaudsW, H .... 20

Mayer-f^ross, W. ... 132

Mebanazine {see Actomol)
von Medima, L. ]. - - -22

Megalomania .... 267
Megaphen {tee Chlotpromazine)
Melandioha, involutional - 119,266

— origin of term • - - 10

Mellenl {see Thioridazine)

Memory(ifs), delusional - - 49

— disorders of {tee alto Amnesia) 47-50

— — in schizophrenia - - 130

— essential steps m - - 48

— falsifications of - ' » 49

— minute - • » • 48, 105

— tests, simpls .... 246
Meningitis ..... 148

— tuberculous, amnestic syndrome

Menorrhagia ....
Menstrual disorders - > • (

Mental defect . . . -

— defiaency, illness in . •

paedophilia in - » -

— deterioration ....

— disorder • • 63, 225,

— — classification of • .

— — legal definitions of -

— Health Act (1959) -

— — Officer ... 224,

— — Review Tnbunals . .

— — (Gotland) Act (1960)

Semce, commuiuty and

— hospit^ acute patient in

— — admission procedures
compulsory admission to •

— — day pauents in -

general principles of organ*

— — reason for admission to • 187

rehabilitation in - - 188

— therapeutic community m - 189

— lUneas, causation of - - - 2

— mechamsms .... 222

— Welfare Commission - - 224

— — Officer - - - 214, 268

Mepaslon (lee Meprobamate)

Mepazine - ... - 197

Mependine ... 108, 204, 207

Mephenesin carbamate . 200, 201

Meprobtmtte 85, 121, 169, 192, 200, 301

286

INDEX

IMcretnn (ite Rpraiaf)

.^}etcfilne ...

F. A. •

Metabolic duordera m

cautoni* - -

— — achhophtenia ... 127
Metapaycholofry .... 268
•Methadone ado/cBon ... 108

— block - - . - 108

— - in treacment of opiate addiction

107. 108

Methallenoeatnl .... 181
Methednne . - - - . 218

• - 210,220

- m

- m, 305
pcnodic

a-methyldopa
Methylpen^l carbamate • - 200

Methylpentynol .... 200
Methylphenidate • - 122, 202

Metonytna * • - • - 47

•Meyer, A. - • - - 20-1

Mieiopiia .... 40, 268

^illto^vT) (tee Meprobamate]

Mind, economici of - • ■*'

— ttrwcture of • - *

Muhetrinf . . . •

Miatdenti^uoR, delueiottel •

Mitjehen ....

Mitmaehen (eo.«pention) •

^iu(d t(Teenv« t<

Moditcn (ree Fluphenttine)

Mongoliim, tnaomy in •

Menu, £..•••
^ionoa(IuB« oxidtae inhibitera

122-3. 204-5

^ daneetoua combinaaona

of, tnth other druga 123, 204

Monro, T. 18

Mood, abnormal autea of > >52

— in Alehetmer'e duease - - 1S5

— definition of -

— deJuajonaJ

— in dementia

— depreaaion -

— dmmal viriationa of

— Koraakoff'a^ayndrome

— Pick'a diseaae •

— achizophKma
Moral iraoecile -

— injarnty -

- 52
44. 256

151, 162

- 117
77, 117

120

156

268

268

Morel, JB. A.

Moreagm. G B • - - -12

Moriaon, Sir A - * • '19

Morphine addiction • • 107-9

— — abatinence ayndronie m

(Tahiti) - . - 107

— — diagnoais of - - • 108

— — treatment of - - * JOS

— and hyoacme aa ledatne - * 191
Moma. N - - - • - 98
Mother, rtlalionshipa with, aa cauie

of mental illneaa - • - _ 5

Motor diaotdera, claasifieautm of SS-60
Moumuie and melancholia • - 116

MoremenCf, abnormally induced - 57

— fhorttlom .... 57

— expreaaive, ditordera of - - 56

— goal-directed, diaorderi of > 56

— reactive, ditordera of - • 56

— ipontaneous, diaordert of > 57

MOUer-lIegeman relaxation tech*

192

‘MOnchhauaen ryndrome’ • • 69

Murder, apex .... 234
aaaa extension of fuicide- • 234

— mental lUneas and * • 60, 65

— mottreleaa .... 234

— psychiatric aspects of - 233-5

— ttditaa - ... - 173

— sexual ..... 234
Muscle relaxanta in electroconvul.

aive therapy .... 210
MuuUtien and murder * • 173

Mutism ... 60, 77, 268

Mjranetin (ire Mepbeneiin)

NAAOsaisst ... 25, llfi>26S

Nartoanalysii .... 218
Ntrcolepiy - . . 23, SI. 263

Narcosis, eoniinusi . . >214

Nardil (iff Phenelrine)

Navane (tet Thiothaine)

Necrophilia - • - • 176

Negativtam - ... 59, 268

Nembutal (rrr Pentobarbitone)
Neologisms * . . » • 47

Nervous nstem, Ptrlovian types of 33
Nculsetd (irr Pencyaxine)

NrurastbaAis .... 369

— PsvIoTisn ibeery of . . 33

Neuron - . . - . 269

Neuropsythistty .... 259
Neurosis, Adlenan theory of . • St

— trunul ..... 33

— character (ire Character neurosii)

— compensation ... 81

— electro-cncephalograph in * 239

— engagement - ... 81

— expcrtmentti .... 262

— Freudian iheoryof - • 2S, 73

— Jungian theory of . • *32

— obsMiDna>(ieeOba<iaions] state)

. . 269

. 273

129-30 — traumatic

Neurotic depresnon . . - oj
Nialamide .... - 204
Nianud {see Nislsmide)

Nicotinamide

........ abeniine)

Nitrogen retention in periodic cata-
tonia ..... 132
* Noo.restramt movement ’ - 12-13

NwtnpryJjne - - . _ 123. 203

Norwegian seamen, achuophrenii in 6
Notensyl (see Acetylpromaaine)

NuUitj of marriage and inumty - 229

Nuixe*a role in treatment
Nuiae-paiient ratio in hospital wards 188
Nymphomama > «

. 17i, 172

INDEX

287

Obesitt ..... 96

Object 269

— choice ..... 269

— Lbido 269

— relations - - - - 26

Oblivon Oe« Melhylpentynol)

Oblivon C (irr hlethylpentyl carbs*

Obsession^s), crinrunal beha\'iour

resulting from . . - 83

— definition of - - - 43, 269

— in depression .... |17

organic states • • 83, 84, 143

— • schizophrenia - - - - 84

Obsessioim compulsive behanour 83

— ideas - . - - - 43

— impulses - - - - 44

personality (sti Personality.

obsessional)

— phobia .... 44, S3

— reactions - - - - 83

— ruminations - - - - 44

—

_ — anxiety and depression in • 83

— — differentul diagnosis of • 84

— — prefrontal leucotomy in 83. 213
_ — psychoanalytic theory of 27, 69

— ~ treatment of • - *84

Obatruetien • • • *130

Occupation and mental illness • 6

Occupational therapy ... 189
Oculogync cnsea .... 84

Oedipus complex ... 26, 209

Old age (res Aged)

Onanism ..... 269
Oneirophrenia .... 132
Operations and menial illness • 9

Opiate addiction ... 106-9

— — diagnosis of - . * 108

— — treatment of - * * 108

Opposition ..... 38

Oral eroticism .... 269

— sadistic stage ofhbidinal develop.

— stage .... - 115

Organ infenonty - - - - 30

— neurosis (res Psychosomatic dis-

Organic hallucinosis ... 143

— state ^Fig. 1) 35. 64, 139-66, 236

catatomc syndrome in - 143

“ — classification of - - * 140

— — exogenous paranoid halluci-

natory syndrome in . 143

— — expansive confabulatoiy syn-

drome in - - - 144

— — focal syndromes in • - 146

hallucinations in 36, 38, 39,

40,41,142,143,149

— — illusions in - - - 35

— — irreversible ... |44
murder in ... 235

— — psranoid ... - 143

puerperal .... 159

— — reversible .... 140

— — atuporose .... 142

— — suicide in - - - - 236

Organic state, transit ayndromes in 142

— — tnilight .... 142

Onentation .... 50, 269

Orphenadnne hydrochloride - 125
‘ Othello ’ syndrome - - - 86

Osennclusion - - - - 47

Oxazepam .... 192, 201

Orypettine ..... 208

Pacatac. {tee Mepaztne)

Paedophilia ..... 175
Palilalia .... 60, 155

Palimpsest {tee Blackout)

Panic 33

Paraesthesia .... 270
Parakinesia ----- 57

Paraldehyde - - 104, 191, 192

Paralogia ..... 270
Paralysis agitans, depression in - 120
Paramnesia ----- 49

Paranoia ..... 270

— Kraepebn’a defimtion of - - 133

Paranoia depression ... 134

— penontbTy - - - - 70

— reactions .... 86

— achizoid position - - - 29

— aehizophrrnia . . - 134

— states 133

— — organic .... 134

— — lemie .... 166

Paraphasia • • - • 80, 270

Paraphrenia ... 133, 270

— bte 166

Parent-child relationships in Mhuo-

phrema .... ]27
Parental aratudea and menul illness 5
Pareooovite . • . • 104

Paresis ..... 270

— general (ira General paresis)

Panetal lobe lesions in Alzheimer's

disease ..... 155

— — — spisxia in - - - 62

— — — disordertofbodyimagein 41

— — — heautoscopy and - - 38

PaikinsoTusm - - 148, 396, 170

— dnig-induced .... 196

Parnate (tee Tranylcypromine)

Parstelm (ree Tranylcypromine)

Passivity, feelmgi of - - - 130

Pathogemc, definition of - - 270

Pathognomonic, defimtion of - 270
Pathological intoxication - 103, 270

Pathoplastic factors ... 270
de Paul, St. Vincent - - - II

Pavlov, 1. P,, theories of - - 32

Penis envy - . . . .26

Pentamelhylenetetrazol - - 22

Pentnhaihuatie - - llO, 191, 193

Pentothal (see Thiopentone sodium)
Peptic ulcer ... 90-3,270

— — causes of • - - - 92

— — personabty in - - 90, 93

— — treatment of - - .93

Perccpnon, disorders of - 35-41

Fencyazine .... 192, 197

Perphenazine 82. 125. 137, 192, 198

288

INDEX

Perplenty - . - . . 5*

PerMVfntion - - 57 , 60

Ptrson* . - - • 31-2,270

Penonal idiom . — • .47

Penonality(ies), abnormat 63-75, 2S4

— — citssieeation of • • - 63

— — Schneider’a classification of 67-6

— accentuated . - . 6&-72

— affeetionleas - - - - 73

— anal ..... 69

— aninkaaiie ... 68, 2SS

— anxious .... 72, T7

— change in cpilepsv ... ISl

— — following brain iryury - 152

— compultne (ire Personality,

anankaatic)

— cycloid ..... 66

— cyclothymic - - 71,114,360

— deroonscrative ... 70

— depressive .... 114

— epileptoid .... 68

— fanatieil - - - - - 72

— hypochondnacaldcvetopmentsin 8S-6

— hypomamc • - - 72. 172

— bj^rencal • ♦ 65, 69 , 365

— involvement of, in neurofii and

MycKosia .... 63

— imtable . - - • • 114

— Jungtan types of • - -3!

— manic ..... Ji4

— mood'tabde .... 72

— multiple • . • • • 80

— obteaaional (ree Pertonility,

ananlime)

— overieove .... 72

— overpersistent ... 71

— overpreose .... 69

— oversenous • - » - 72

— paranoid - - 66, 70, IJJ-4

— Pavlovun tywi of - - - 33

— prcmorbid, in schuophienia • 126

— pteKnalionof.inartenoselerottc

S choeu .... 165

cpathic fire a/10 Paycho-
path) ... - - 64

guardianship and • *67

— — Henderson's views on - 65

— — Ueonhard’a views on * 68-72

— — Schneider’s views on • 67-8

— psychosomatic illness tnd 89-90

— querulous parsnoid • . • 86

— resctive-Ubile - - - 71

— schizoid ... 65, 326

— sensitive - - * - 72

— fubdepressive - . . 72

— uricontrolled .... 63

— weai-willed - - - - 73

Pertofrm (srt DesinnpramineJ
Perversion, sexual - - J7J-S0

Pethidine (ire Mependme)

Petit msl epilepsy. electro.encephtlo-

grsph m - - ' . 239

— — status ... 143-4

Petnlowitsch, L. • • • .64

Pfrcpfhebephfenia ... 270

Pballic SMge of iibidinil develop-

ment - - • - 26. 2T0

'Phantom limh' ... 41,270

Phenazin ..... 12$

Phencyclidine .... 207
Phenelzine .... 124.204

Phnupratine .... 204
Phenmetmine .... 195
Phcnobarbiione ... 192, 193

PhciwKhiazines 23. 82. 85, 104, 110.

122, US. tsr, m.

196, 200, 202. 204
Phenotype ..... 271
Phenytoin sodium • . - 110

Phobia - - - 53,83,271

— rondiiioned > - - . 53

— olMesiional - - - - 53

— misuse of term - - 46, 53

Phonemes (ice afro Halluciiutioni,

auditory) .... 104

— in achizoehrrnu ... 129
Physeptone (ler hfelhadone)

Physical disease, causation of • 2

— > factors m cauaation of mental

lUnesa .... 8-9
Physique, athletic ... 256

— dyspUaue • • • .261

— I^eaemie .... 267

— pybiie ..... 272

Psekenoff, C. 3)’. • • . » 97

Piek'a disease ... 145, 155

Pinel.P 12

Pipradol ..... 202
Pleasure-ptin principle • > 271

PofyneuntiS .... 105

rost.«ofteuisionat tyndrome . . 153

Post-encrphaliiie sutea 56, 147, 257
Pott-epiJeplic automatism > * 150

Post-hypnooc suggestion - - 217

Poatute, disorders of - - .58

Poverty, delusions of • • - 46

Praminsdole .... 204

Pregnancy and mental illness 8, ISS
Prcludifl (ire Phenmetrazine)
Premenstrual tension and mental

iJ^ss - - ... 8

Preventive detention ... 67

Prupism .... - 170

Primary gam ... 79, 271

Pruon, moital illness in • • 7

Pntchar^J. C. .... 19

Process course of illness - 135,271

— primary ■ - - * 29, 271

— sccondszy .... 274

Ptodromata .... 271

Projection - - - - 27, 271

Prolixity - .... 43

Promazine .... 196,200

I^neniseuily, sexual, in hypomaiua 173
— — psychopathic disorder and

225, 272

Ptondol (we Iprindole)

Prond^e (tee Praminadole)

Property, protection of - - - 228

ProUupendyl hydrochloride - 20,138

moEX

Romberg’s sign - . . -

Rosenbaum, G. • - • -

Roih, M. - ... -

Royal College o{ PhysicSsna of Cdin-

— Edinburgh IIospiUl for Nervous
and Mental Disorders •
Ruminations, obsessional

Schizophrenia in prison •

— ptO^OSlB of • - -

— psychoanalytic theory of -

Sadism .... 173,274

Sadomasochism, psyrhoanaJytical

theonei of ... . 174

Sake). M. 21

Saroten (rea Amitryptyline)

Satynasit ..... t7d
Swage, G. .... 20

Schizoid, definition of . • . 274

Schizophasia .... 374
Schaephnnis.adoleiecnteritea and 134

— aetiology of _ - - - - 126

— ambivalence in • • . S5

— > spophanoua experiences m 44-5, 55

— broken homes and • • • 127

— catatonic - • > .131

— eiasa diitnbunoo of - • 6

~ course of illneaa in • • « 13S

— defiftiuon of . • . 126, 274

... delualons in ... . 124

— damenua rnecoz and . . 16

— depenontlixation in . . S4

— dinetenuai diagnotia of • - 136

dfsorden of behaviour in • * 130

— - censciousneu in • . 130

— — emooonal ezprcation in • 130

-- — memory iti ... IJO
-- 'doubte~bind' theory of 127, 169, 186
-- electroconvulaive therap^r for 137,212

— clectro.encepbtlosrsphin

133. 115.240

— endocrine duordera in - * 127

— enviconmental factors in . - 5-6

~ and epilepsy .... 32

— erotomania in ... 87

— ezpectation of ... 3

— expressive movements in • 56

— following brain injury * - !$♦

— genetic prophylaw of • - 138

•— genetics of ... - 3

naliuananoas m 36, 37, 3S, 39, t29

hebephrenic - - - 59, 13l

~hi$toryot ... J3-16

— in unmigrants • . • • 6

— insight in • ... 63

— msuJin coma therapy in • 137, 209

— Klinefelter tyndmme in - * 4

— latent - - - - - 132

— mania and .... 135

— metabobc disorders in - - 127

— murder m _ . . . * 23+

— in Norwegian seamen . - 6

— obsessional symptoms in 44, 84

— paranoid . * 328, 13J, 134

— perplexity in - • * .54

— physical treatment of • • 137

— prefrontal leucotomy m - 138, 213

— premorbid personality in • • 127

— social treatment of * * • 136

— speech disorders in - * 60-2,130

— suicide in .... 236

— symptomatolow of • - « 125

— iDought disorder m • 46, 128-9

Schnauzknmpf .... 56

Schneider, K. . . 64, 67, 134

— dassifieation of abnormal per-

aonatines by . . . 67-8

Sctirdder, P., ballucinatory tyn*

dromes of . . . .40

Scobne (tea Suxunethonium cMot*
ide)

Sooptophilia ... 174, 274

Scotland, compulsory admission to

hospital ns ... . 226

— Mental Welfare Commissioa in 224

— plea of pirotl nexpoR«bi2i(y to 231

— pimection of pgtieni't property

Scott, K. r I I I I 11
Senbenma Largua ... 32

Seoooal (m OuuHlbarbiione)

Secondary gain . . .79,82,274

— proti** ..... 274

Sedation .... 191-2

Seduction of children ... 179
Sejunenon ..... 16

Seiuie dementia (tte Dementia,

senile)

Sense decepuens . . 33-^

— distortions ... 4<Vl

Sensory deprivation ... 36

Serenare (jee Halopcridol)

Seienid D free Oxazepam)

Srrnfl (>fe Pbencycbdine)

Sex and mental lUneiS ... 8

Sexual disorders ... 167-82

— — classification of ... 167

— dnse, disorders of direction of 173-82

inieniityof - - 168-72

— fantasies in obsessional person-

alitiea ..... 68

intercouise, normal frequency

— perversions, psychoanalytic

theones of . . . . 172

— — treatment of - • 180-1

Sexuality, infantile • - 1 8, 25

‘Shadow', Juogian concept of - 32

Signal tyatema, first and second . 32-3
Sieruficance, experiences of • .44

Siliinets in heb^hrenia . . 59

Ekae, D 19

Sleep, depnvation of - - - 52

— thi^ets . - 51-2, 76, 119

~ _ in anxiety .... 76

~ _ depression . ... 119

— rhythm, inversion of . * 52

Soeisl sdspcadon .... 63

Soaety ot Friends, foundation of

‘The Retreat' by ... 12

INDEX

291

FACE

Sodium amylobubitone * 110,121

— amytal (j« Sodium amylobarbi-

— thiopentone .... 211

Sopor * • * • - 200, 275

Spanne (tee Promazine)

Speech, disordera of - - - 60

Spbttmg, mechanism of - - 29

Spontaneous movements, disordera

Stelazine (tee Tnfluoperazme)

Stereotopy - - - - 47, 57

Stdb<mtrol • - - - • 181

‘Stir crazy’ . - 7

Stirling District Asjhtm - - 20

Stress, mental illness and • - 2, 7

Stupefaction . . . > 51

Stupor 58, 59. 77, 80. 1 17, 130, 275
Subconscious .... 275

Subdepressise personality - - 72

Subdural haematoma . . • 153

SubjecDve ezpenencet • - • 63

Sublimation ... 27, 275

Subnormality ... 225, 275

— severe .... 225. 274

Suggestion in psychotherapy 216-17

Suicidal patients, management of . 184

— nsk 237

Suicide (tee also under tptafie dit‘

eotei) 8,9,14,65.93,118.

121, 152. 157. 164. 235-7

— attempted ... 235, 236

— barbiturates and ... 194

— broken homes in - • • 235

— psychiatric causes of ♦ - 256

— seasonal vanauons in • • 9

— successful .... 255

Superego • • • • 24, 275

Suimontil (lit Trtmipramme)
SuzametboruuR) dalonde • • 210

Sydenham, T. .... 12

Sydenham’f chorea, inrolunury

movements jn - - - 57

Symbolism . - - - . 275

SymboUastion ... 24, 29

Sympathetomimetic amines • - 109

Synaesthesia . • - - 39

Syndrome - - - . . 275

Syphilis as cause of general

paresis .... - |48

Tacwvcamiia, paroxysmal
‘Talking past the point’ (tee olio
Vorbeireden) ...
Tarsetan (see Chlorprothixine)
Temple sleep ....
Temporal lobe epilepsy, personality

TemporowKcipiu! cortex, dyi
fopisia in lesions of
Tension ...

— premenstrual .

Terror ui delinum tremens
Testamentary capacity .

Testosterone - - - - 109

TeCrabenzme - - • . 199

Thanatos .... 25, 174

Tberipeutic community - .189

Theta rhythm .... 238
Thiamme deficiency - - - 105

T hinkin g, asyndetic - - 47, 256

— autistic .... 42, 256

— dereistic .... 260

— incoherent ... 43, 265

— self-reference of * - .47

Thiopentone sodium ... 218
Thioproperazme .... 138

Tbiondizine 122, 125, 137, 192, 197, 202
Thtothiiine . - - - - 208

Thorazine (see Chlorpromazine)
Thought, alienation of • • 44, 128

— blocking ... 43, 128

— broadcasting - ... 44

— disorder - - 42-7, 263, 27S

— — elanification of - . - 42

— — of content of . • - 44

— — form of - • . .46

— — formal ... 46, 263

— — — in schizophrenia - - 128

— — of possession of . . >43

— wiihdrtwai .... 44

Thyroid treatment in periodic cau-

loiua ..... 138
Thyrotoucoiii * * - - 275

T«4 5. 57

Tofranil (see Imiprarmne)

Tolnatc (see Prothypendyl hydro-
chloride)

Tolseram (set Mrphenesm catba-
male)

Toteion dystonia ... 125
Torticollis, spasmodic . - • 57

Trance, hypnotic ... 217

'Traniiuillo-sedativcs ... 200

■Tranquillizers ... 196-200

Transexualism ... 177, 275

Transference ... 214, 275

Transvestism ... 177, 275

Tranylcypromine . - 124,204

Treatment, plan of - . - 187

— aituabon, control of - .185

— symptomatic ... 192-5

Tremor . - - 57, 203, 257

— in debnum tremens ... 103

— Jakob Creutzfeldt disease - 157

TncWorvl .... 191, 194

Tricks played by patients . - 59

Tnfluo^azine - - 125, 137, 198
Tnfluopendol ... - 200

Tnlafon (ire Perphenazine)

Tnmipramine ... 123, 203

Tnpendol (see Tnfluoperidol)

Tnptizol (ire Amitryptylme)

Tnsomy .... 4, 275

Toinal .... 110. 193

Thie, D. H .... 20

292

INDEX

TwiUght lUte

— — epiketic . - • -

— — hysterical • - - - 80

Twini, binovuUr * * % ifJ

— uniovular - - , ■ ^5

— achuophrenie, atudies of • - 3

71,80, 151,276 Volition, disorden of, la achizo*

. • ]j| phrcnia .... ]}}

Votbeireden . - 47,80,130,276

Voyeunim ... - 174, 276

276

31, 32

Ui£tWivi coUu» -- -

Uncinate fits * • • •ISO

Unconacioua - 2^, 28, 31, 32, 276

— collective . - - 32, 2S8

— Ftemjiin theory of -

— individual ••

— Jungian theory of -
‘Und<nttndibihty’ «a «i

achuophrenia
Undoing . . -

*Un£t to plead* -
Urethral eroticism
Urticaria ...

64, 126

VacmAL hypo-aesihesia
Vafftniainua

Vallium (ire Diaiepam)
Vaaomoter rhuuui
Veriguth’a aign -

- - 92

- - 56

15,60.130

^'<at^ dtitortion* (r« Dyernega-

~ halluciaationa (re* HaUuei-
fUBoaa, viiutl) , „

Vltamiri B complex (i« Peren-

ttoviwl • • . • * 10^

— — defidency aieauaecfdemen-

W'AlSNES-jAtRECC, 7- • * -21

Wal*er-BOel, H • - - - 158

Wat and meotd tUneaa . - - 7

Water retention, premenstrual . 8

during reserpme therapy - 199

Watts, J. W 23

Waxy flexibility (ire Flexibilitas

Wcttschweifigkeit (see also ProUaity) 43
WeUdonn (see DichloraJphrnaronr)
Wenucke. C. • . • . 16

WciTuckea encephalopathy ■ 105-6

Westphal, C. - - • • 14

Weyer.J 11

tt’.if.O. fxpert Comnuttee - • 100

Wiklcr'a pkarmacodynimic utter-

pretauon of drug addiction . Ill
'Will to power’, Adlerian - - 30

Wilaon’a diieaae . . - . 157

Wiah-fulfllmcnt, dftam as ■ - 29

Witchraft and mental lUnes* * - 11

Withdrawal syndrome - • - 276

iv^ aalad ... - - 276

'Voting, diiordera of • • .60

12

♦ m

Yofuc Aaylum . . -

^oorHiUA. erotic ... 76